dfcolumljia  ©mbergitp 

COLLEGE  OF  PHYSICIANS 
AND   SURGEONS 


Reference  Library 

Given  by 


Digitized  by  the  Internet  Arciiive 

in  2010  witii  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/principlespractiOOemme 


THE 


PRINCIPLES  AND  PRACTICE 


OF 


CTNiECOLOaY. 


BY 


THOMAS  ADDIS  EMMET,  M.D., 

SURGEON    TO    THE  WOMAN'S   HOSPITAX,    OF    THE   STATE   OF    NEW  TOKK,  ETC. 


WITH   ONE  HUNDRED  AND  THIRTY  ILLUSTRATIONS. 


PHILADELPHIA: 

HEISTET     O.     LEA 

1879. 


Entered  according  to  Act  of  Congress,  in  tlie  year  1879,  by 

HENRY    C.    LEA, 

in  the  Office  of  th.e  Librarian  of  Congress.     All  rights  reserved. 


PHILADELPHIA  : 
COLLINS,     PRINTER. 


TO  THE 

MEMORY  OF  MY  FATHER 

JOHN  PATTEN  EMMET,  M.D., 

MANY  YEARS  PROFESSOR  OF  CHEMISTRY  IN  THE  UNIVERSITY  OF  VIRGINIA, 

WHO  DIED  IN  1842  : 
AX   HOKEST    MA:N", 

ESTEEMED    BY    ALL   "WHO    KNEW    HIM. 

TO    HIS   EXAMPLE    AND    EARLY   TRAINING   I   OWE    MY    SUCCESS   IN    LIFE; 

IN  YOUTH  I  AIMED  TO  MERIT  HIS  APPROBATION; 

IN  MANHOOD  I  HAVE  STRIVEN  TO  BE  WORTHY  OF  HIS  GOOD  NAME. 


%\lh  lofllt  is  also  f  ebkatt^ 


TO  MY  MANY  FRIENDS  IN  THE  PROFESSION, 

WHO  HAVE  ATTEXDED  MY  CLINICS  AT  THE  WOMAX'S  HOSPITAL: 

TO  THEM  I  FEEL  IT  SHALL  BE  WELCOME, 

SIXCE  THEY  WILL  HAVE  ALREADY  PUT  INTO  PRACTICE  MUCH  THAT 

IS  NOW  PRESENTED  IN    THIS    NEW  FORM 
BY 

THE    AUTHOR. 


PREFACE. 


This  work  is  essentially  a  clinical  digest.  It  includes  the  results 
of  my  individual  experience,  and  aims  to  represent  the  actual  state  of 
gynaecological  science  and  art. 

For  the  past  twenty-five  years  I  have  devoted  myself  to  the  study 
and  treatment  of  the  diseases  of  women,  and  have  been  continuously 
engaged  in  the  service  of  the  Woman's  Hospital  of  the  State  of  New 
York  since  its  opening  in  1854.  From  1862  to  1872  I  was  the 
surgeon-in-chief,  with  entire  medical  control  and  sole  responsibility 
in  the  treatment  of  its  inmates. 

In  the  beginning  the  capacity  of  the  hospital  did  not  exceed  that 
of  an  ordinary  sized  dwelling.  In  1862,  and  subsequently,  through 
the  efforts  of  Mr.  A.  C.  Wetmore,  Yice-President  of  the  Board  of 
Governors  (in  whose  honor  the  structure  is  called  the  "  Wetmore 
Pavilion"),  means  were  secured  for  erecting  a  handsome  edifice,  espe- 
cially adapted  for  its  purpose.  It  was  built  under  my  personal  super- 
vision, organized  by  myself,  and  brought  to  a  high  state  of  prosperity 
before  any  change  was  paade  in  its  management.  In  1872  there  were 
added  to  the  medical  staff  three  other  gentlemen  whose  eminence  in 
gynaecology  is  well  known.  They  have  shared  with  me  the  responsi- 
bility, and  have  done  much  to  enlarge  the  reputation  and  usefulness 
of  the  institution,  which,  for  several  years,  was  the  only  hospital  of 
this  special  character  in  the  world.  Up  to  the  date  of  this  reorgan- 
ization about  three-fourths  of  all  the  patients  admitted  had  been  under 
my  care,  and  I  had  performed  even  a  larger  proportion  of  the  surgi- 
cal operations.  To  the  enormous  clinical  advantages  thus  available 
have  been  added  those  of  my  private  hospital,  now  in  operation  six- 
teen years,  and  those  of  an  extensive  consulting  practice. 

I  have  thought  it  proper  to  give  this  brief  account  of  the  clinical 
field  from  which  such  a  large  portion  of  the  fruits  herein  presented 
have  been  gathered,  in  order  to  explain  the  individuality  which 
the  work  may  possess.  In  attempting  to  ascertain  and  formulate 
the  laws  which  apply  to  diseases,  and  to  analyze  the  results  of  treat- 


VI  PREFACE. 

ment,  I  have  compressed  numerous  histories  and  facts  into  a  number 
of  statistical  tables,  which  present,  in  brief  space,  information  that 
hundreds  of  pages  would  scarcely  have  sufficed  to  contain  in  detail. 
Their  parallel,  it  is  believed,  is  not  to  be  found  in  the  whole  range 
of  gynaecological  literature,  and  if  they  unfold  to  others  what  I 
have  aimed  to  put  in  them,  I  shall  feel  compensated  for  the  labor 
they  have  involved.  For  two  continuous  years  they  kept  me  occu- 
pied in  hours  not  required  for  professional  work,  and  to  the  minutest 
detail  they  have  been  prepared  by  myself,  for  I  felt  that  their  value 
rested  on  their  accuracy,  which  I  could  not  have  vouched  for  if  their 
compilation  had  been  committed  to  others. 

In  addition  to  my  own  experience,  I  have  endeavored  to  record 
that  of  other  authors  whenever  available,  aiming  always  to  include 
what  I  felt  was  useful,  and  to  exclude  rigorously  what  I  knew  to  be 
erroneous  in  precept  or  practice,  so  that  the  work  might  faithfully 
mirror  what  I  conceived  to  be  the  true  aspect  of  gynfecology.  It 
will  be  observed  that,  with  the  exception  of  the  two  plates  taken  from 
Savage's  work,  and  some  of  the  instruments,  all  the  illustrations  are 
original,  the  drawings  having  been  furnished  by  myself. 

If  I  have  omitted  to  give  due  credit  to  any  one  for  priority  in,  or 
special  contribution  to,  the  elucidation  of  any  subject,  it  has  been 
through  inadvertence,  for  I  would  account  no  man's  labor  as  my  own. 

For  obvious  reasons  I  have  been  silent  upon  all  diseases  and  con- 
ditions not  peculiar  to  women ;  and  I  have  not  thought  it  necessary  to 
insert  formal  prescriptions  in  the  work.  No  man  can  prove  successful 
as  a  gynaecologist  who  has  not  mastered  the  principles  of  medicine, 
and  stored  up  experience  in  the  general  treatment  of  disease.  The 
competent  practitioner  knows  that  prescriptions  must  be  varied  with 
each  case ;  to  the  incompetent,  ready-made  formulae  are  but  a  snare. 

From  the  first  page  to  the  last  I  have  cherished  the  same  deep 
sense  of  responsibility  that  every  conscientious  physician  must  feel 
at  the  bedside  of  a  patient  whose  life  is  in  his  hands ;  and  in  com- 
mitting this  work  to  my  brethren  I  can  truly  say  that  it  reflects  the 
best  part  of  a  career  that  has  not  been  idle  or  lacking  in  earnestness 
of  purpose,  and,  I  trust,  not  spent  in  vain. 

89,  Madison  Avenue,  New  York. 
March,  1879. 


CONTENTS. 


CHAPTER  I. 


The  Relations  of  Climate,  Education,  and  Social  Conditions  to  Develop- 
ment ..............       17 

Effect  of  tlie  American  climate  upon  longevity,  nutrition,  development, 
and  generation — Are  we  to  become  an  enfeebled  race  ? — Early  impres- 
sions on  the  nervous  system  are  permanent,  and  are  transmitted  to  de- 
scendants— Causes  of  imperfect  development  of  young  -women — Active 
culture  of  the  brain  in  the  develoj)ing  period  incompatible  with  the 
normal  growth  and  function  of  uterus  and  ovaries. 

CHAPTER  II. 

Instruments  Used  in  Examinations 23 

Specula  :  Sims's,  Emmet's — Depressor — Tenacula — Sims's  copper  sound 
— Emmet's  probe — Sponge-holder — Long-nozzled  syringe — Sims's  eleva- 
tor— Emmet's  elevator — Applicator — Case  of  gynsecological  instruments 
— Sponge  tents — Method  of  preparing  them — Emmet's  uterine  dilator, 
by  sponge  and  by  water — Rules  for  using  sponge  tents — Laminaria 
tents — Tupelo  tents. 

CHAPTER  III. 

SuKGiCAL  Instruments  and  Appliances 41 

Scissors  of  various  curves — Ball-and-socket  knife — Needles  —  Sims's 
needle-holder  —  Emmet's  needle  forceps  —  Sims's  feeder — Twisting  for- 
ceps—Sims's  shield — Double  tenaculum — Sims's  blunt  hook — Counter- 
pressure  hook — Silver  wire — Mode  of  freshening  surfaces,  before  the 
introduction  of  sutures  —  Silver  sutures,  and  mode  of  introduction  — 
Mode  of  administering  vaginal  injections  of  hot  water — Foster's  vaginal 
syringe — Vaginal  tampon  ;  its  use  and  mode  of  application. 

CHAPTER  IV. 

Form  for  a  Record  op  Cases  ;   Mode  of  Examination  ;   Chief  Points  for 
Forming  a  Diagnosis  .......••••       57 

Blank  forms  for  records — Neatness  in  person  and  instrument — Examina- 
tion table — Digital  examination  :  its  value  ;  mode  of  making  it ;  points 
to  be  noted — Conjoined  examination — Physical  signs  of  a  retro  verted  . 
uterus  ;  of  a  flexed  uterus  ;  of  a  uterine  fibroid — Enlarged  uterus  :  dif- 
ferentiated from  pregnancy,  and  from  other  bodies,  growths,  tumors, 
hemorrhagic  collections,  etc. — Condition  of  vagina,  urethra,  bladder, 
cervix  uteri,  perineum,  rectum  —  Dilating  the  urethra,  a  reprehensible 
practice — Mode  of  using  the  speculum — Points  to  be  noted — Use  of  probe — 
Latent  cellulitis. 


Vlll  CONTEisTS. 


CHAPTER  V. 

PAGE 

Causes  of  Disease,  Reflex  and  Direct  ••.....       Ttj 

Influence  of  ganglionic  or  sympathetic  system  of  nerves — Faulty  nutri- 
tion— Uterine  congestion  and  inflammation — Effect  of  increased  weit^ht 
of  the  uterus — Influence  of  the  ovaries  upon  the  uterine  condition — Sub- 
involution— Constipation — Influence  of  fruitfulness  and  sterility  upon 
growths — Difference  between  a  fibroid  and  a  fibrous  tumor — Active  exer- 
cise renders  the  uterus  less  liable  to  conditions  arising  from  celibacy — 
Cancer  and  corroding  ulcer — Atrophy  of  uterine  body — Accidental  causes 
of  disease:  1.  Products  of  inflammation  and  hemorrhage  ;  2.  Injuries  of 
the  cervix  and  displacements  ;  3.  Injuries  of  the  vagina  and  its  outlet ; 
4.  Results  of  inflammation  of  mucous  glands  of  the  vagina,  uterus,  Fal- 
lopian tubes,  and  ovaries. 

CHAPTER  VI. 

Pbiuciples  of  General  Treatment         ........       94 

Confidence  of  the  patient  essential  to  success — Influence  of  the  mind  over 
disease — Anjemia — Method  of  improving  digestion  and  nutrition — Influ- 
ence of  sunlight — Influence  of  diet,  etc. ;  coffee,  stimulants,  anodynes — 
Habitual  invalids — Dress — Hours  for  meals,  etc. — Importance  of  details. 

CHAPTER  VII. 

Local  Treatment  .         .         .         .         .         .         .         .         .         .         .         .118 

The  condition  of  the  circulation  in  the  pelvis — Its  influence  on  local  dis- 
ease— Must  be  corrected  before  any  permanent  advance  can  be  made — 
The  effects  of  electricity,  cold  and  heat  in  exciting  contraction  of  vessels 
through  reflex  action — Hot-water  vaginal  injections  ;  history  and  mode 
of  use. 

CHAPTER  VIII. 

Principles  of  Treatment,  Continued  ;  Displacements,  Pelvic  Circulation, 
Lining  Membrane  of  the  Uterus,  Applications  to  the  L'terine  Canal  .  125 
Proper  position  of  the  uterus — The  essential  principle  is  to  remove  ob- 
struction to  the  uterine  circulation — Positions  eitlier  too  low  or  too  high 
are  objectionable — Campbell's  pneumatic  repositor — Chronic  inflamma- 
tion and  ulceration  do  not  exist — Remedies  :  Nitrate  of  silver — Carbolic 
acid — Glycerine — Iodine  —  Use  of  applicator  —  Powdered  substances — 
Pith  of  corn  stalk — Sponge  tents  to  reduce  size  of  uterus — Injections  of 
Churchill's  tincture  of  iodine  into  uterine  cavity — Hot  water  in  the  ute- 
rine cavity — Blisters  to  the  cervix — Hyperaesthesia  is  not  inflammation. 

'  CHAPTER  IX. 

Ovulation  and  Menstruation 147 

Nerve  supply  of  the  ovaries — Puberty — The  uterus  not  the  dominant 
organ  of  the  female — Menstruation  not  always  due  to  ovulation — Disin- 
tegration of  the  lining  membrame  of  the  uterus  during  menstruation — 
Causes  which  determine  early  or  late  menstruation — Table  I.,  showing 
age  at  first  menstruation,  for  single,  sterile,  and  fruitful  women  ;  and 
whether  menstruation  was  regular  or  not — Table  II.,  showing  the  percent- 


CONTENTS.  IX 

PAGB 

age  on  the  whole  number  menstruating  at  a  given  age — Table  III.,  show- 
ing the  percentage  in  relation  to  regularity  or  irregularity — Table  IV., 
regularity  further  analyzed  —  Table  V.,  pain  during  menstruation,  in 
reference  to  health,  disease,  and  sterility — Table  VI.,  showing  proportion 
suffering  pain  with  menstruation  for  each  menstrual  age — Table  VII., 
showing  further  relation  of  pain  to  menstruation — Table  VIII.,  pain 
during  menstruation  for  all  conditions  —  Table  IX.,  showing  average 
duration  of  the  flow — Table  X.,  showing  duration  of  flow  with  reference 
to  circumstances  of  first  menstruation — Table  XL,  changes  in  duration 
of  flow  in  after-life — Table  XII.,  menstrual  changes  as  to  quantity  and 
duration. 

CHAPTER  X. 

Abnokmal  Changes  in  the  Menstrual  Flow  .......     174 

Deviations  from  the  normal  standard — Amenorrhoea — Scanty  menstrua- 
tion— Menorrhagia — Membranous  dysmeuorrhoea — Vicarious  menstrua- 
tion— Hysteria. 

CHAPTER  XI. 

Congenital  Absence  and  Accidental  Atresia  op  the  Vagina  ;  Mode  op 
Operating  for  Establishing  the  Canal,  and  Evacuating  Retained  Men- 
strual Blood 203 

Causes  of  retention — Mode  of  relief — Table  XIII.,  exhibiting  cases  of  im- 
perforate hymen,  congenital  absence  of  uterus,  and  accidental  occlusion 
— Cause  of  death  when  the  uterus  has  been  emptied  of  its  contents — 
— Proper  mode  of  treatment — Cases. 

CHAPTER  XII. 
Pelvic  Hematocele         ...........     234 

Definition — History — Applied  terms — Source  of  the  blood — Frequency — 
Symptoms — Varieties — Differential  diagnosis — Treatment. 

CHAPTER  XIII. 

Diseases  of  the  Pelvic  Cellular  Tissue        .......     255 

Description  of  the  tissues — The  influence  of  cellulitis  not ,  fully  appre- 
ciated as  a  cause  of  disease  in  the  uterus  and  ovaries — Etiology — Symp- 
toms and  treatment  of  cellulitis — Tables  showing  the  causes,  complica- 
tions, and  location  of  cellulitis,  and  the  condition  of  the  menstrual  flow 
as  influenced  by  cellulitis — Symptoms — Treatment — Dr.  Brickell's  con- 
clusions. 

CHAPTER  XIV. 

Displacements  of  the  Uterus        .........     288 

Anatomical  supports  of  the  uterus — Normal  position  of  the  uterus — 
Pelvic  roof — Downward  displacements,  or  prolapse — Causes — Versions  ; 
forward,  backward,  lateral — Causes  of  versions — Flexures. 

CHAPTER  XV. 

Etiology  and  Treatment  of  Uterine  Versions       ......     295 

Tables  XVIII.  to  XXIII.  inclusive,  showing  the  relations  of  versions  to 
menstruation,  marriage,  celibacy,  fruitfulness,  sterility,  pregnancy,  age, 
pain,  etc.,  also  percentages — Treatment  of  versions. 


CONTENTS. 


CHAPTER  XVI. 

PAGE 

Pessaries 314 

Proper  time  for  their  use — Peculiarities  to  be  met — Object  of  pessaries 

Individual  forms — Block-tin  for  modelling — Adjusting  pessaries. 

CHAPTER  XVII. 

Etiology  of  Uteeixe  Flexures       .........     326 

Tables  (XXIV.  to  XXX.)  showing  the  relations  of  flexures,  general  and 
special,  to  marriage,  celibacy,  pregnancy,  miscarriage,  menstruation, 
etc.  etc. — Anteflexures — Retroflexures — Lateral  flexures. 

CHAPTER  XVIII. 

Teeatmex't  of  Flexures  of  the  Uterus  .......     351 

Errors  in  pathology — Intra-uterine  stem  pessaries — Dilatation — Curved 
tents — Division  of  cervix. 

CHAPTER  XIX. 

Procide>-tia,  or  Prolapse  of  the  Uterus 366 

Causes — Etiology  ;  Table  XXXI.,  showing  the  relation  of  procidentia  to 
age,  pregnancy,  injury,  labor,  and  other  conditions — Treatment,  pessa- 
ries, surgical  measures — Cystocele — Rectocele. 

CHAPTER  XX. 

Laceration  of  the  Perixeum  .........     384 

Efl"ects  of  laceration — Mode  of  operating — Introduction  of  the  sutures  and 
securing  the  wires — Laceration  through  the  sphincter — Mode  of  ope- 
rating— Causes  of  failure — Table  XXXII.,  showing  relation  of  laceration 
through  the  sphincter  to  age,  pregnancies,  labors,  etc. 

CHAPTER  XXI. 
Inversion  of  the  Uterus        ..........     408 

Causes — Frequency  —  Symptoms  —  Diagnosis  —  Treatment — Method  of 
Valentin,  White,  Tyler  Smith,  Xoeggerath,  Courty,  Simpson,  Barnes, 
Nott,  Emmet. 

CHAPTER  XXII. 
Sub-involution  of  the  Uterus         .........     443 

CHAPTER  XXIII. 
Laceration  of  the  Cervix  Uteri  .........     445 

History — Etiologj- — Tables  XXXIII.  to  XXXVII.  inclusive,  being  anal- 
yses of  lacerations — Influence  on  menstruation. 

■CHAPTER  XXIV. 

Diagnosis  and  Treatment  of  Lacerations  of  the  Cervix  Uteri    .         .         .     458 

CHAPTER  XXV. 

Amputation  of  the  Cervix  Uteri 481 

Never  called  for  except  for  malignant  disease — True  elongation  of  the 


CONTENTS.  XI 

PAGE 

cervix  does  not  exist — Double  laceration  often  mistaken  for  elongation — 
What  is  the  true  condition  ? — Treatment  by  the  cautery — Intra-uterine 
stem  pessary — Mode  of  amputating — Cicatricial  cervix. 

CHAPTER  XXVI. 

Cancer  of  the  Uterus,  Vagina,  Rectum,  and  External  Organs  of  Genera- 
tion     490 

Definition  —  Varieties — Etiology  —  Rare  among  Negroes — More  common 
among  the  richer  than  among  the  poorer  classes — Tables  XXXVIII.  and 
XXXIX. —  Epithelioma — Sarcoma — Corroding  ulcer — Cancer  of  external 
oi'gans  of  generation. 

CHAPTER  XXVII. 

Description,  Etiology,  and  Diagnosis  of  Fibrous  Growths  of  the  Uterus    .     514 
Mode  of  formation — Etiology — Tables  XL.  to  LII.  inclusive — Diagnosis. 

CHAPTER  XXVIII. 

LoGAL  AND  General  Treatment  of  Fibrous  Growths  of  the  Uterus      .         .     545 
Action  of  ergot,  opium,  alum,  gallic  acid,  cinnamon — Incision  of  tumor — 
Enucleation — Partial  removal — Disintegration — Tapping  a  fibro-cyst. 

CHAPTER  XXIX. 

Surgical  Treatment  of  Fibrous  Growths  of  the  Uterus       ....     564 
Pedunculated  fibroids  —  Polypi — Ecraseur  —  Removal  by  traction  —  Re- 
moval of  the  ovaries  for  profuse  hemorrhage  from  fibrous  tumors. 

CHAPTER  XXX. 

Diseases   of   the  External  Organs  of  Generation,  Cervix,  and  Uterine 

Canal 592 

Elephantiasis  and  hypertrophy  of  labia  and  clitoris — Fibrous  and  fatty 
tumors — Oozing  tumor — Labial  cysts — Vaginismus — Vaginitis — Disease 
of  the  cervix  and  uterine  canal. 

CHAPTER  XXXI. 

Vesico-  and  Recto-Vaginal  Fistula       ........     614 

History  and  development  of  the  operation — Silver  sutures — Button  suture 
— Preparatory  treatment — Mode  of  operating. 

CHAPTER  XXXII. 
Different  Forms  of  Fistula  .........     626 

Vesico-vaginal — Urethro  vaginal — Ureto-vagiiial — Recto-vaginal. 

CHAPTER  XXXIII. 

Statistical  History  of  Vesico-  and  Recto-Vaginal  Fistula  .         .         -     658 


CHAPTER  XXXIV. 


Diseases  of  the  Urethra 711 


xii  CONTENTS. 

CHAPTER  XXXV. 

PAGE 

Cystitis.     Stone  in  the  Bladder  and  Uebters      ......     724 

CHAPTER  XXXVI. 
Diseases  of  the  Ovaries        ..........     746 

Ooplioritis — Enlargement — Treatment — Battey's  operation. 

CHAPTER  XXXVII. 
Tumor  of  the' Ovary      ...........     758 

Solid  (fibrous)  tumors — Cystic  tumors  :  follicular  cysts  ;  compound  cys- 
tomata  ;  myxoid  and  dermoid  cystomata  ;  cystoma  proliferum  papillare  ; 
C.  parviloculare  ;  C.  sarcomatosum  (cystosarcoma)  ;  C.  myxomatosum — 
Retrograde  metamorphosis  of  cystomata :  fatty,  sclerotic,  atrophic,  hem- 
orrhagic, purulent,  spontaneous  perforation — Development  of  cystomata. 

CHAPTER  XXXVIII. 

Cystic  Tumors  of  the  Ovary  (Continued) 769 

Unilocular  cysts  (monocystic,  oligooystic) — Multilocular  cysts  (com- 
pound, proligerous,  polycystic) — Stages — Rapidity  of  development — 
Symptoms — Diagnosis . 

CHAPTER  XXXIX. 

Abdominal  Tumors         ...........     778 

Contents  of  abdominal  tumors  and  ascitic  fluid  considered  in  relation  to 
diagnosis. 

CHAPTER  XL. 

Treatment  op  Ovarian  Cystic  Tumors  . 788 

Internal  remedies  —  Surgical  treatment:  tapping;  injection  of  iodine; 
drainage  ;  vaginal  ovariotomy  ;  abdominal  ovariotomy. 

CHAPTER  XLI. 

Conditions  which  may  Complicate  the  Operation  of  Ovariotomy  .         .     799 

Inflammation  of  the  sac — Peritonitis  and  ascites — Adhesions — Size  and 
long  existence  of  the  tumor — Pregnancy — Cancer — Phthisis — Renal  dis- 
ease— Uterine  fibrous  tumors — Disease  of  the  other  ovary. 

CHAPTER  XLII. 

General  Details  in  Ovariotomy 814 

Proper  time  for  operating— Preparatory  treatment — Instruments — Pre- 
parations for  the  operation — Mode  of  treating  the  pedicle. 

"chapter  xliii. 

Abdominal  Ovariotomy 830 

Steps  of  the  operation — After-treatment:  antiseptic  dressings;  dosing 
of  the  incision  ;  reduction  of  temperature  (quinine,  cold  water  applica- 
tions, "fever  cot"). 


LIST  OF  ILLUSTRATIONS, 


1.  Sims's  speculum 

2.  Emmet's  retractor 

3.  Sims's  depressor 

4.  Sims's  tenaculum 

5.  Emmet's  tenaculum 

6.  Sims's  copper  sound 

7.  Emmet's  silver  probe 

8.  Sims's  sponge-holder 

9.  Long-nozzled  syringe 

10.  Sims's  elevator 

11.  Emmet's  elevator 

12.  Emmet's  applicator 

13.  Gryniecological  case 

14.  Emmet's  sponge  dilator 

15.  Emmet's  water  dilator 

16.  Emmet's  scissors  . 

17.  Emmet's  scissors  . 

18.  Emmet's  scissors  . 

19.  Emmet's  ball-and-socket  knife 

20.  Emmet's  needles 

21.  Emmet's  needles 

22.  Emmet's  needles 

23.  Sims's  needle-holder 

24.  Emmet's  needle-forceps 

25.  Sims's  "  feeder" 

26.  Emmet's  twisting  forceps 

27.  Sims's  shield 

28.  Emmet's  double  tenaculum 

29.  Sims's  blunt  hook 

30.  Emmet's  counter-pressure  hook 

31.  Mode  of  inserting  sutures 

32.  Mode  of  inserting  sutures 

33.  Mode  of  securing  sutures 

34.  Mode  of  twisting  sutures 

35.  Mode  of  adjusting  sutures 

36.  Foster's  vaginal  syringe 

37.  Vaginal  touch  and  bimanual  examination 

38.  Retroverted  uterus 

39.  Subperitoneal  fibroid  and  anteflexion  of  the  uterus 


PAaE 
23 
25 
26 
26 
26 
27 
27 
27 
27 
28 
28 
30 
31 
32 
35 
41 
42 
42 
43 
44 
44 
44 
44 
45 
45 
45 
46 
46 
46 
47 
48 
49 
49 
50 
51 
53 
63 
64 
65 


XIV 


LIST    OF    ILLUSTRATIONS. 


FIQ. 

40. 
41. 
42. 
43. 
44. 
45. 
46, 
47. 
48. 
49. 
50. 
51. 
52. 
53. 
54. 
55. 
56. 
57. 
58. 
59. 
60. 
61. 
62. 
63. 
64. 
65. 
66. 
67. 
68. 
69. 
70. 
71. 
72. 
73. 
74. 
75. 
76. 
77. 
78. 
79. 

80. 
81. 
82. 
83. 

84. 
85. 
86. 

87. 


The  normal  or  health  line 

Campbell's  "pneumatic  repositor" 

Absence  of  vagina,  and  retained  menstrual  blood 

Double  uterus  and  vagina,  with  retention 

Occlusion  of  the  vagina  .... 

Retro-uterine  hematocele 

Hematocele  in  the  peritoneum 

Hematocele  ruptured  into  the  peritoneum 

Pessary  for  cellulitis         .... 

Transverse  section  of  the  pelvis  (Savage) 

Left  half  of  pelvis  in  section  (Savage)   . 

Flexure  of  the  cervix       .... 

Mode  of  collecting  a  retroversion 

Pessary,  modification  of  Hodge's 

Pessary  applied  for  retroversion 

Rubber  disk  pessary        .... 

Lines  of  incision  in  flexure  of  the  cervix 

Lines  of  incision  in  flexure  of  the  body 

Pessary  for  procidentia    .... 

Long  lever  pessary  for  procidentia 

Sims's  operation  for  procidentia 

Author's  operation  for  procidentia 

Folds  formed  in  the  operation  for  procidentia     . 

Sims's  oiJeration  for  cystocele 

Emmet's  operation  for  cystocele 

Position  of  the  flaps  .... 

Diagram  of  old  operation  for  lacerated  perineum 

Diagram  of  author's  operation  for  lacerated  perineum 

Operation  for  lacerated  perineum 

Outline  of  denudation  for  lacerated  perineum    . 

Diagram  of  parts  in  contact  in  lacerated  perineum 

Method  of  securing  the  ends  of  the  sutures 

Diagram  of  ruptured  sphincter  ani 

Faulty  introduction  of  suture 

Proper  introduction  of  sutures    . 

Inversion  of  the  uterus    . 

White's  repositor  .         .     . 

Emmet's  mode  of  reducing  an  inverted  uterus 

Inverted  uterus,  with  fibro-cystic  tumor 

Diagram  showing  direction  of  traction  exerted  by  sutures  after 

reduction  of  inversion 
Internal  laceration  of  the  cervix 

Unilateral  laceration,  producing  obliquity  of  the  uterus 
Uterine  tourniquet 
Lacerated  cervix,  after  denudation 
Cicatricial  plug  in  a  lacerated  cervix 
Cicatricial  hypertrophy  after  laceration 
Diagram  of  surfaces  to  be  denuded 
Bifid  laceration  of  the  cervix 
Double  tenaculum,  separating  the  flaps  of  a  laceration 


partial 


PAGE 

128 
130 
206 
208 
221 
243 
247 
252 
286 
289 
290 
293 
311 
317 
321 
323 
357 
363 
373 
375 
378 
378 
378 
381 
382 
382 
386 
389 
393 
394 
394 
395 
401 
402 
402 
410 
416 
421 
429 

432 
462 
462 
467 
468 
469 
471 
471 
472 
474 


LIST    OF    ILLUSTRATIONS. 


XV 


pio. 

89.  Multiple,  or  stellate,  laceration  of  the  cervix 

90.  Effect  of  laceration  involving  the  vaginal  wall 

91.  Diagram  of  laceration  involving  the  vagina 

92.  Self-retaining  intra-iiterine  stem 

93.  Stump  after  amputation  of  the  cervix    . 

94.  Interstitial  and  sub-peritoneal  fibroids   . 

95.  Multiple  fibroids  ... 

96.  Pedunculated  fibroids 

97.  Emmet's  ecraseur 

98.  Mode  of  adjusting  the  ecraseur  chain 

99.  Emmet's  enucleator 

100.  Fibrous  tumor,  projecting  into  the  vagina 

101.  Fibrous  tumor,  partially  removed 

102.  Elephantiasis  of  the  labium  and  hypertrophied  clitoris 

103.  Oozing  tumor  of  the  labia 

104.  Structure  of  oozing  tumor 

105.  Emmet's  curette  forceps 

106.  A  vesico-vaginal  fistula  . 

107.  Sims's  vaginal  glass  plug 

108.  Sims's  self-retaining,  or  sigmoid,  catheter 

109.  Fistulous  tract  after  healing  of  a  lacerated  cervix 

110.  Small  fistula  in  front  of  the  cervix 

111.  Fistula,  involving  the  whole  base  of  the  bladder 

112.  Vesico-vaginal   fistula,   with   loss  of  anterior   lip  of  cer) 

113.  Cervix  uteri  united  to  neck  of  bladder  to  secure  retention 

114.  Recto-urethral  fistula  in  a  man 

115.  Recto-vaginal  fistula  (rectal  surface) 

116.  Skene's  endoscope 

117.  Emmet's  cystitis  eyelet    . 

118.  Bache  Emmet's  fistula  tube 

119.  Papillary  growth  in  a  cyst 

120.  Papillary  projections  after  rupture  of  a  cyst 

121.  Emmet's  aspirator 

122.  Thomas's  trocar    . 

123.  Weir's  steam  spray  apparatus 

124.  Wells's  clamp 

125.  Thomas's  clamp    . 

126.  Dawson's  clamp    . 

127.  Storer's  clamp  shield 

128.  Wells's  trocar 

129.  Emmet's  trocar     . 

130.  Skeene's  needle    . 


CORRIGENDA. 


Page  43,    7th  line  from  the  bottom, /or  "  eye"  read  "  edge." 

"     76,17th    "        "      "        "        /or  "  fulness,"  read  "  feebleness." 

"     79,  in  the  last  column  of  the  table,  for  "vagina,  and  outlet  of  Fallopian  tubes," 

read  "vaginal  outlet  and  Fallopian  tubes." 
"    119,  6th  line  from  the  bottom,  insert  a  period  after  "  out,"  and  begin  the  new 

sentence  with  "  After  soaking  in  hot  water." 
"     261,  bottom  line, /or  "phthisis"  read  "phlebitis." 

"     317,  the  title  of  figure  53  should  be  "  Pessary  (modification  of  Hodge's)." 
"     652,  the  title  of  figure  115  should  be  "  Recto-vaginal  fistula,  rectal  surface." 


THE  PRmCIPLES  AND  PRACTICE 


GYNJ]COLOGY. 


CHAPTER    I. 

THE  RELATIONS  OF  CLIMATE,  EDUCATION,  AND  SOCIAL  CONDITIONS 
TO  DEVELOPxMENT. 

Effect  of  the  American  climate  upon  longevity,  nutrition,  development,  and  gene- 
ration— Are  we  to  become  an  enfeebled  race  ? — Early  impressions  on  the  nervous 
system  are  permanent,  and  are  transmitted  to  descendants — Causes  of  imperfect 
development  of  young  women — Active  culture  of  the  brain  in  the  developino^ 
period  incompatible  with  the  normal  growth  and  function  of  uterus  and  ovaries. 

A  THINKING  man,  who  has  had  opportunities  for  observation,  can- 
not divest  himself  of  the  apprehension  that  the  physical  development 
of  the  women  of  our  land  is  becoming  deteriorated.  If  this  be  true, 
the  causes  should  be  quickly  sought  out  and  removed,  or  we  must 
eventually  become  an  enfeebled  race,  after  the  human  stream  which 
has  given  us  vigor  ceases  to  flow  into  our  country  from  other  lands. 

It  has  been  asserted  that  the  tendency  is  for  all  animals  to  dete- 
riorate in  this  country,  and  indeed  archaeologists  give  abundant  proof 
that  several  races  of  men  bad  peopled  the  American  continent  and  died 
out  before  our  own  occupied  it.  In  few  portions  of  the  globe  has  there 
been  a  like  occurrence  from  natural  causes  ;  nations  have  overrun  and 
assimilated  the  previous  occupants  of  a  country,  but,  having  once  be- 
come populated,  the  land  has  continued  to  be  occupied.  The  cause 
of  this  deterioration  is  as  yet  obscure,  but  the  question  as  to  whether 
the  peculiar  nature  of  our  climate  has  a  share  in  it  forces  itself  upon 
us.  When  immigration  to  the  United  States  shall  have  ceased,  and 
our  population  shall  have  become  more  homogeneous,  the  problem 
will  be  somewhat  simplified. 

We  certainly  possess  a  most  changeable  climate,  which  taxes  the 
nervous  system  at  the  expense  of  nutrition,  and  stimulates  to  constant 
2 


18      THE  RELATIONS  OF  CLIMATE,  EDUCATION,  AND 

action,  rendering  us  a  restless  people  in  both  mind  and  body.  Rest  and 
quiet  recreation,  in  a  European  sense,  are  unknown  to  the  mass  of  our 
population.  We  develop  early,  and  live  a  life  crossed  by  more  than  our 
share  of  dyspepsia,  neuralgia,  and  other  nervous  disorders.  The  ave- 
rage degree  of  intelligence  I  judge  to  be  greater  in  this  than  in  any 
other  country,  on  account  of  our  heterogeneous  origin.  Our  field  of 
education  is  as  extensive  as,  if  not  more  so  than,  that  of  our  neighbors, 
but  it  is  more  superficial.  Profundity  is  granted  to  comparatively  few, 
since  the  same  mental  application  on  which  a  German,  in  his  own  land, 
would  thrive,  will,  in  this  country,  impair  the  physical  condition,  or 
result  in  some  serious  nervous  disorder.  With  no  lack  of  perseverance, 
we  generally  accomplish  an  undertaking,  but  the  end  is  gained  only 
at  the  expense  of  a  vast  amount  of  wear  and  tear.  We  are,  from 
necessity,  eminently  a  practical  people,  and  are  always  seeking  the 
most  direct  method  by  which  we  may  accomplish  a  purpose.  In  this 
peculiarity  lie  our  hopes  for  the  future. 

We  cannot  escape  the  disadvantages  of  climate  under  which  we  live 
and  pay  so  heavy  a  tribute  for  the  privilege.  But  we  can  diminish  the 
tax  by  protecting  more  fully  the  young,  and  especially  the  girl,  until 
she  has  reached  a  degree  of  physical  development  which  will  render 
her  less  susceptible  to  disease,  better  able  to  perform  her  maternal 
duties,  and  capable  of  bringing  forth  an  increased  progeny.  This 
development  can  be  accomplished  only  by  assisting  nature  to  expend 
the  full  nervous  force  of  the  child  in  its  organic  growth,  and  by  leav- 
ing the  training  of  the  brain  to  a  later  period  of  life. 

On  the  approach  of  puberty  the  nervous  system  becomes  the  domi- 
nant element  in  the  female  organization,  and  is  as  susceptible  to  exter- 
nal influences  as  is  the  barometer  to  atmospheric  changes.  But  the 
simile  is  not  applicable  later  on,  since  an  impression,  for  good  or  evil, 
once  made  upon  the  nervous  system,  especially  wdiile  in  the  period  of 
development,  is,  in  all  probability,  never  erased.  It  may  lie  dormant 
in  the  after  life  of  the  individual  if  circumstances  do  not  occur  to 
bring  the  consequences  again  into  view,  hnt  the  impression  will  be 
transmitted  through  the  child  to  future  generations. 

It  is  in  the  developing  period  of  life  that  the  young  girl  lays  the 
foundation  of  a  defective  organization,  Avhenever  nature's  laws  have 
been  disregarded.  She  Avill  then  be  rendered  liable  to  local  disease 
before  marriage,  to  sterility  afterwards,  or  to  the  life  of  an  invalid 
from  the  birth  of  her  first  child,  and  her  enfeebled  constitution  will  be 
transmitted  to  her  offspring. 

The  life  of  a  boy  and  girl  is  passed  side  by  side  with  an  equal 


SOCIAL    CONDITIONS    TO    DEVELOPMENT.  19 

degree  of  development  imtil  the  eleventh  or  twelfth  year.  From  this 
time  forth,  until  old  age,  their  life  lines  diverge.  The  boy  gradually 
develops  from  birth  to  manhood ;  the  generative  function  with  him  is 
perfected  without  special  tax  to  his  nervous  system,  and  stimulates 
his  physical  growth  even  w4ien  he  is  placed  under  disadvantageous 
circumstances.  Defects  in  physical  education  can  be  counteracted,  in 
after  life,  to  a  much  greater  extent  in  the  male  than  is  possible  in  the 
female. 

With  the  female  the  transition  to  womanhood  is  rapid  ;  her  organs 
of  generation  become  the  chief  power  in  the  complex  organic  system, 
and  to  reach  the  necessary  co-ordination  she  passes  through  the  great 
crisis  of  her  life.  Her  nervous  system  is  fully  taxed  in  securing  this 
harmony  of  action,  and  in  preserving  it  afterwards.  The  slightest 
defect  in  her  organs  of  generation  will,  through  the  sympathetic  sys- 
tem, produce  functional  derangement  elsewhere.  If  the  defect  be  a 
serious  one,  nutrition  throughout  the  body  becomes  impaired  for  the 
want  of  a  healthy  nervous  stimulus.  The  original  exciting  cause  of 
the  disturbance  cannot  be  remedied ;  growth  is  arrested ;  waste  is  not 
repaired,  and  atrophy  follows. 

With  the  first  step  to  womanhood  the  young  girl  begins  to  live  an 
artificial  life  as  a  tribute  to  a  degree  of  civilization  and  progress  which 
is  only  consistent  in  a  general  disregard  of  all  laws  of  health.  The 
"  girl  of  the  period"  is  made  a  woman  before  her  time,  by  associating  too 
much  with  her  elders,  and  in  diet,  dress,  habits,  and  tastes  becomes, 
at  an  early  age,  but  a  reflection,  on  a  reduced  scale,  of  her  older 
sisters.  When  she  has  reached  the  customary  age  to  be  introduced 
into  society  it  is  but  a  nominal  step,  since  she  is  thoroughly  conversant 
with  it,  and  is  as  well  able  to  look  to  her  own  interests  as  a  veteran. 
She  may  have  acquired  every  accomplishment,  and  yet  will  have  been 
kept  in  blissful  ignorance  of  the  simplest  laws  of  her  own  organization 
or  requirements  for  the  preservation  of  her  health.  Her  bloom  is  as 
transient  as  that  of  a  hot-house  plant,  where  the  flower  has  been  forced 
by  cultivation  to  an  excess  of  development  by  stunting  the  growth  of 
branches,  and  limiting  the  spread  of  its  roots. 

There  are,  fortunately,  many  exceptions  to  the  rule,  but  society  is 
so  constituted  that  the  most  conscientious  parent  cannot  entirely  pro- 
tect a  daughter  from  the  force  of  example,  and  to-day  almost  every 
young  girl  in  the  land  suffers  more  or  less  from  a  pernicious  form  of 
physical  and  mental  training. 

A  girl  scarcely  enters  her  teens  before  custom  dictates  a  change  in 
her  mode  of  dress ;   her  shoulder-straps  and  buttons  are  exchanged 


20     THE  RELATIONS  OF  CLIMATE,  EDUCATION,  AND 

for  a  num'ber  of  strings  to  be  tied  about  her  waist,  and  the  additional 
weight  of  an  increased  length  of  skirt  is  added.  She  is  unable  to  take 
the  proper  kind  or  necessary  amount  of  exercise,  even  if  she  were 
not  told  that  it  would  be  unladylike  to  make  the  attempt.  Imper- 
ceptibly her  waist  is  drawn  into  a  shape  which  was  never  intended  by 
nature  for  the  organs  placed  there,  and,  as  the  abdominal  and  spinal 
muscles  are  seldom  brought  into  play,  they  become  atrophied.  Under 
any  circumstances  the  abdominal  organs  are  compressed  and  displaced. 
The  woman  needs,  more  than  the  man,  full  play  of  the  abdominal  wall, 
that  with  the  descent  of  the  diaphragm  the  venous  blood  may  be  aided 
in  its  return  to  the  heart.  It  is  true  that  by  custom  for  centuries  the 
waist  of  the  female  has  been  compressed,  but  the  evil  was  to  a  great 
extent  counteracted  by  the  observance  of  laws  for  the  preservation  of 
health,  now  disregarded.  Before  puberty  most  girls  have  already 
begun  to  suflFer  from  habitual  constipation,  a  condition  which  is  likely 
to  last  through  life.  From  compression  of  the  abdominal  viscera,  and 
from  constipation,  the  venous  circulation  in  the  female  pelvis  becomes 
obstructed  early  in  womanhood.  This  interruption  to  the  current  ends 
in  permanent  enlargement  and  over-distension  of  these  vessels,  a  fruit- 
ful source  of  disease,  as  we  shall  see  hereafter. 

As  soon  as  the  change  is  made  in  the  dress,  from  that  of  a  child, 
custom  demands  also  that  she  should  be  protected  by  veil  and  gloves 
from  the  rays  of  the  sun,  and  she  soon  becomes  as  blanched  as  a  well- 
cultivated  celery  stalk.  And  since  the  blood  needs  the  chemical  effect 
of  sunlight  acting  directly  on  the  skin,  anemia  is  established  chiefly 
from  the  deprivation.  This  state  of  the  blood  is  a  potent  factor  in 
the  generation  of  all  diseases  depending  on  impaired  nutrition,  and 
entails  conditions  likely  to  baffle  all  medical  effort  at  their  removal 
during  the  menstrual  life  of  the  female. 

At  this  time,  with  the  blood  deficient  in  every  element  for  proper 
stimulus  to  the  nerve  centres  which  preside  over  organic  growth,  an 
attempt  is  made  to  develop  the  brain.  At  the  period  of  life  when  the 
young  girl's  whole  nerve  force  is  taxed  for  the  full  development  of  her 
organs  of  generation,  we  deflect  this  force  by  hard  study,  or,  it  may 
be,  for  the  acquirement  of  some  accomplishment,  which  in  all  proba- 
bility will  be  forgotten  or  laid  aside  after  marriage.  The  spirit  of 
emulation  which  is  cultivated  in  all  schools  has  a  deleterious  influence 
on  the  nervous  system  of  girls  at  any  age,  but  particularly  about  the 
time  of  puberty,  while  those  who  are  the  least  fitted  to  bear  the  strain 
are  always  the  ones  who  make  the  most  effort.  Music  also,  from  its 
emotional  effect  on  a  sensitive  nervous  system,  has  arrested  the  de- 


SOCIAL    CONDITIONS    TO    DEVELOPMENT.  21 

velopment  of  the  ovaries  and  uterus  of  many  a  young  girl.  On  look- 
ing over  my  case  books  I  have  been  surprised  to  find  the  same  state- 
ments repeated  again  and  again,  viz.,  that  the  sufferer  had  taken 
the  highest  honors  at  some  noted  female  school  or  college,  and  gave 
no  tangible  signs  of  weakness  until  reaction  took  place  after  her  return 
home. 

I  hold  that  it  is  not  practicable  to  educate  a  girl  by  the  same  method 
found  best  fitted  for  the  boy,  without  serious  consequences  afterwards. 
More  than  all,  it  is  an  impossibility  to  fully  develop  the  ovaries  and 
brain  at  the  same  time,  for  the  growth  of  the  former  will  be  arrested. 
Even  when  the  course  of  study  has  been  comparatively  moderate, 
functional  disturbance  is  of  too  frequent  occurrence  to  admit  a  doubt 
as  to  cause  and  effect. 

We  are  indebted  to  the  late  Dr.  Edward  H.  Clarke,^  of  Boston,  for 
two  valuable  treatises  on  this  most  important  subject,  and  already  it  is 
evident  that  promising  results  are  to  spring  from  his  good  work.  I 
have  long  appreciated  the  necessity  for  some  radical  change  in  the 
mode  of  educating  the  children,  and  especially  the  young  girls  of  this 
country,  but  to  overcome  the  evil  has  heretofore  seemed,  indeed,  a 
hopeless  task  in  opposition  to  prejudice  and  pecuniary  interest.  I 
not  only  fully  indorse  Dr.  Clarke's  views  as  being  in  accordance  with 
my  own  experience,  but  claim  that  the  evil  results  are  even  more 
serious  than  he  has  represented. 

I  would  advocate  the  highest  degree  of  education  for  woman,  in 
keeping  with  her  means  and  station,  but  the  wrong  method  and  the 
wrong  period  of  life  have  been  settled  upon  for  acquiring  it. 

To  reach  the  highest  point  of  physical  development,  the  young  girl 
in  the  better  classes  of  society  should  pass  the  year  before  puberty 
and  some  two  years  afterwards  free  from  all  exciting  influences.  She 
should  be  kept  a  child  as  long  as  possible,  and  made  to  associate  with 
children.  Her  dress,  diet,  and  habits  of  life  should  be  carefully 
looked  after  as  if  she  were  a  child,  and  above  all,  the  habit  of  regu- 
larity should  be  observed  in  all  details.  Her  mind  should  be  occupied 
by  a  very  moderate  amount  of  study,  with  frequent  intervals,  of  a  few 
moments  each,  passed  when  possible  in  the  open  air.  There  should 
be  no  studying  at  night  under  any  circumstances.  Each  menstrual 
period  should  be  passed  in  the  recumbent  position  until  her  system 
becomes  accustomed  to  the  new  order  of  life,  and  the  habit  of  regu- 

1  Sex  in  Education,  or  a  Fair  Chance  for  the  Girls,  Boston,  1873.— The  Building 
of  a  Brain,  Boston,  1874. 


22  THE    RELATIONS    OF    CLIMATE,   EDUCATION,   ETC. 

laritj  established.  She  should  neither  expose  herself  nor  over-exercise 
for  twenty-four  hours  before  the  expected  period,  and  during  the  time 
she  should  discontinue  her  lessons.  When  the  menstrual  function  has 
become  perfectly  established,  so  as  to  be  normal  in  character  and  free 
from  pain,  she  can  begin  to  increase  the  number  of  her  studies,  but 
at  the  time  of  the  molimen  she  should  observe  the  same  rule  of  rest, 
mental  and  physical.  Then  let  the  young  woman  spend  the  same 
years  in  the  completion  of  her  education  as  are  given  by  the  young 
man  to  his  collegiate  course,  when  she  will  have  reached  a  better  age, 
and,  with  ordinary  care,  be  in  better  physical  condition  for  her  work. 
This  would  necessarily  delay  her  entrance  into  society  for  several 
years,  and  at  the  age  of  twenty-five,  when  she  would  have  acquired 
her  growth  and  full  physical  development,  she  would  be  better  fitted 
to  become  a  wife.  If  custom  would  allow  some  approximation  to  this 
plan,  I  believe  the  women  of  our  country  would  bear  more  children, 
be  better  able  afterwards  to  discharge  their  maternal  duties,  and 
would  preserve  their  youth  and  vigor  many  years  longer. 

Women  of  the  poorer  classes  menstruate,  as  a  rule,  later  than 
those  in  the  upper  walks  of  life,  but  reach  their  full  physical  develop- 
ment sooner.  This  is  the  natural  result  of  a  simpler  mode  of  life,  by 
which  even  a  certain  amount  of  privation  and  want  is  more  than 
counterbalanced  by  less  waste  of  nerve  force.  A  simple  mode  of  life 
for  the  girl,  therefore,  fits  the  woman  the  better  for  an  early  marriage, 
and  renders  her  more  capable  of  discharging  her  duties  as  a  mother. 


INSTRUMENTS  USED  IN  EXAMINATIONS.         23 


CHAPTER  II. 

INSTRUMENTS  USED  IN  EXAMINATIONS. 

Speciila  :  Sims's,  Emmet's — Depressor — Tenacula — Sims's  copper  sound — Emmet's 
probe — Sponge -holder — Long-nozzled  syringe — Sims's  elevator — Emmet's  ele- 
vator— Applicator — Case  of  gynsecological  instruments — Sponge  tents — Method 
of  preparing  them — Emmet's  uterine  dilator,  by  sponge  and  by  water — Rules 
for  using  sponge  tents — Laminaria  tents — Tupelo  tents. 

Various  forms  of  specula  are  in  use  for  examining  the  interior  of 
the  vagina,  and  each  has  its  advocates,  the  favorite  instrument  being 
the  one  to  which  the  operator  has  become  the  most  accustomed. 

I  have  always  used  Sims's  perineal  retractor,  or  mj  own  instrument 
constructed  on  the  same  principle.  Dr.  Sims's  instrument  has  been 
modified  in  various  forms,  and  new  ones  have  been  invented  on  the 
same  principle  with  the  view  of  dispensing  with  an  assistant,  but  as 
yet  nothing  has  been  devised  which  can  take  its  place.  This  instru- 
ment is  so  simple  in  design,  and 
so  perfectly  does  it  fulfil  every  "• 

requirement,  that  it  will  proba- 
bly never  be  superseded.  The 
only  objection  to  be  advanced 
against  it  is  that  an  assistant  is 
required  in  using  it.  This, really, 
is  an  advantage  in  favor  of  the  „.    ,  , 

o  Sims  s  speculum. 

instrument,  for  an   examination 

should  always,  if  possible,  be  made  in  the  presence  of  a  third  party. 
It  is  not  necessary  to  have  a  trained  assistant,  for  any  one  with  ordi- 
nary intelligence  can  hold  it  sufiiciently  well,  provided  the  operator 
himself  understands  how  it  should  be  held.  It  is  of  much  more 
importance  to  know  the  proper  position  in  which  the  patient  should  be 
placed  for  the  examination,  and  this  is  the  chief  difiiculty.  The 
instrument  is  generally  made  too  heavy,  and  too  straight  in  its  central 
portion.  When  too  heavy  it  soon  fatigues  the  hand,  even  of  one 
accustomed  to  its  use  ;  and  if  made  too  straight  it  is  apt  to  slip  sud- 
denly out  of  the  vagina. 


24  INSTRUMENTS    USED    IN    EXAMINATIONS. 

As  long  as  the  sole  use  of  the  speculum  was  to  bring  the  cervix 
into  view,  and  to  facilitate  the  passage  of  the  porte-caustique  in  the 
treatment  of  supposed  ulceration,  the  cylindrical  speculum  sufficed. 
With  the  advance  of  knowledge  in  the  treatment  of  uterine  disease,  it 
became  necessary  to  gain  more  space  and  light,  and  the  cylindrical 
speculum  has  gradually  been  superseded  by  various  instruments  with 
expanding  blades  to  open  out  the  upper  portion  of  the  vagina.  But 
nearly  every  speculum  of  the  kind  that  I  have  seen  is  so  long  that  it 
displaces  the  uterus  more  or  less,  and  by  continued  use  tends  to  dilate 
the  upper  portion  of  the  vagina.  I  have  known  both  retroversion  and 
prolapse  of  the  uterus  to  occur  in  patients  from  repeated  use  of  a 
valvular  speculum  which  stretched  the  upper  portion  of  the  passage. 
The  amount  of  space  and  light  obtained  by  any  of  these  instruments 
is  very  small  in  comparison  with  what  is  afforded  by  Sims's  speculum, 
and  they  are  useless  for  all  surgical  procedures. 

The  older  members  of  the  profession  who  have  become  dexterous  in 
the  use  of  some  special  instrument,  cannot  be  expected  to  change  or 
to  appreciate  the  necessity  for  doing  so.  But  for  the  younger  mem- 
bers it  would  be  well  to  begin  with  the  use  of  Sims's  speculum,  if  they 
wish  to  hold  a  position  in  the  advance.  Full  justice,  in  the  light  of  our 
present  knowledge,  cannot  be  done  in  the  treatment  of  uterine  disease 
by  any  other  instrument  than  this  perineal  retractor,  or  some  other 
based  on  the  same  principle,  and  like  it  capable  of  exposing  the  whole 
vagina. 

In  a  single  generation,  the  use  of  this  instrument  has  advanced  the 
knowledge  and  treatment  of  the  diseases  and  especially  the  injuries 
of  woman  from  profound  ignorance  to  a  front  rank,  if,  indeed,  not 
beyond  that  of  any  other  branch  of  surgery. 

My  own  speculum,  or  retractor,^  has  been  in  use  some  eleven  years. 
When  adjusted  it  is  self- retaining,  and  in  many  cases  can  be  used 
without  the  aid  of  an  assistant.  I  have  frequently  used  it  in  long 
surgical  operations  ;  and,  if  we  had  not  Sims's  instrument,  I  would 
recommend  it  as  fulfilling  every  condition,  since  it  acts  on  the  same 
principle.  The  patient  is  placed  on  her  left  side  in  Sims's  position, 
and  the  instrument  is  introduced,  into  the  vagina  by  the  index  finger 
of  the  right  hand,  and  passed  behind  the  cervix,  while  at  the  same 
time  the  perineum  is  firmly  pressed  back  by  placing  the  thumb  of  the 

'  This  instrument  lias  been  credited  to  Weiss  by  Dr.  Barnes,  and  to  Mr.  Spencer 
Wells  by  Dr.  Churchill.  But  I  presented  the  instrument  to  Mr.  Wells  during  his 
visit  to  this  country,  and  Weiss  doubtless  afterwards  copied  it. 


THE    RETRACTOR. 


25 


same  hand  in  front  of  the  screw  at  F.  As  the  instrument  is  held  in 
this  position,  the  screw  B  is  turned  sufficiently  to  revolve  the  vaginal 
portion  into  the  hollow  of  the  sacrum,  and  at  the  same  time  the  fe- 
nestrated blade  becomes  imbedded  in   the  soft  parts  on  the  upper 


Fijr.  2. 


Emmet's  retractor. 


buttock,  with  the  effect  of  retracting  the  perineum.  The  screw  A  is 
for  securing  the  blade  at  such  angles  as  may  be  necessary.  By 
means  of  the  screw  I)  the  upper  half  of  the  vaginal  portion  is 
elevated,  and  with  it  the  right,  or  upper,  labium.  The  instrument  is 
held  in  place  by  the  blade  on  the  buttock,  but,  as  this  surface  is  more 
or  less  movable,  it  sometimes  allows  the  outlet  of  the  instrument  to 
sag,  and  the  os  cannot  always  be  brought  into  view  unless  the  patient 
is  placed  on  a  plane  inclined  from  the  operator.  This  difficult}'-,  how- 
ever, is  easily  overcome  by  the  finger  of  an  assistant  on  the  upper 
part  of  the  blade,  and  I  have  frequently  made  the  patient  hold  it  with 
a  finger  of  the  left  hand,  which,  in  Sims's  position,  is  always  drawn 
out  from  under  her  and  lies  up  over  her  back. 


The  depressor  is  frequently  needed  to  push  back  the  anterior  wall 
of  the  vagina  sufficiently  to  bring  the  cervix  into  view.     It  has  been 


26 


IXSTRUMEXTS    USED    IN"    EX  AMIX  ATIONS , 


made  as  a  spatula  and  in  other  forms,  but  the  original  instrument, 
made  impromptu  from  a  large  silver-plated  copper  sound,  cannot  be 
improved  upon. 


Fi?.  3. 


Sims's  depressor. 


The  tenaculum  is  necessary  for  seizing  the  cervix  and  bringing  it 
into  view,  and  for  steadying  the  uterus  while  examining  or  making 
applications  to  the  canal.     I  had  the  original  instrument  reduced  in 


Fig-.  4. 


Sims's  tenaculum. 


Fig.  5. 


Emmet's  tenaculum. 


size,  made  much  lighter,  and  the  shape  of  the  hook  changed  from  a 
gradual  curve  to  one  coming  oif  at  nearly  a  right  angle,  with  only  a 
slight  curve  at  the  point.  Both  instruments  are  generally  made  too 
blunt,  whereas  the  point  should  be  as  sharp  as  and  taper  like  a  needle. 
The  larger  tenaculum,  introduced  by  Dr.  Sims,  answers  for  making 
examinations,  and  is  often  more  useful  on  account  of  its  strength  and 
size,  but  the  smaller  instrument  is  better  for  seizing  a  portion  of  tissue 
to  be  removed  in  operations. 

Dr.  Sims,  many  years  ago,  had  Simpson's  sound  made  of  copper, 
and  reduced  somewhat  in  size.  This  was  indeed  a  great  improvement, 
since  it  permitted  the  curve  of  the  instrument  to  be  changed  whenever 
necessary.  But  I  found  it  possible  to  be  misled  by  it  as  to  the  actual 
position  of  the  uterus,  for.  when  curved  in  accordance  with  the  impres- 
sion suggested  by  a  digital  examination,  the  uterus  would  sometimes 
conform  itself  to  the  sound.  I  therefore  adopted  the  surgeon's 
silver  probe,  made  longer  and  with  a  handle.  I  use  the  instrument 
simply  to  feel  with,  as  it  were,  when  the  parts  are  beyond  the  reach 


THE    SOUND  —  THE    SPONGE-IIOLDEll — THE    SYRINGE.        27 

of  my  finger,  and  as  it  is  too  delicate  to  move  the  uterus  it  cannot 
mislead  or  do  harm. 

A  piece  of  whalebone  about  eight  or  nine  inches  in  length,  with  a 
rough  thread  cut  on  the  end  like  a  gun  screw,  is  a  useful  device  of 

Fiff.  6. 


SiuQs's  copper  sound. 


Fis.  7. 


Emmet's  silver  probe. 

Dr.  Sims  for  swabbing  out  the  vagina  by  means  of  cotton  twisted 
around  it.  The  cotton  is  easily  thrown  off  when  not  needed,  and  is 
better  adapted  to  the  purpose  than  a  piece  of  sponge.  This  stick  is 
also  very  useful,  as  we  shall  see,  in  tamponing  the  vagina. 

A  number  of  Sims's  sponge-holders  are  needed  for  surgical  purposes, 
and  for  removing  blood  from  the  vagina  in  case  of  accidental  hemor- 

Fig.  8. 


Sims's  sponge-holder. 


rhage  after  an  examination.  They  should  be  made  of  iron,  and  gal- 
vanized, or  copper-plated,  which  is  better,  with  the  handle  of  the 
same  metal,  and  in  one  piece,  for  if  made  of  bone  or  wood  it  soon 
becomes  cracked  from  being  placed  in  hot  water. 


Fig.  9. 


Long-nozzled  syringe. 


To  remove  the  mucous  discharge  from  the  uterine  canal  I  use  a 
long-nozzled  syringe  (Fig.  9)  made  of  hard  rubber,  which  I  bend  to 
the  needed  shape,  for  introduction  within  the  uterus,  by  heating  it  in 


28 


INSTRUMENTS    USED    IN    EXAMINATIONS, 


the  flame  of  a  spirit  lamp.  To  prevent  the  rubber  from  burning  it  is 
necessary  to  grease  the  nozzle  well  before  heating  it.  When  bent  to 
the  proper  curve,  the  shape  is  retained  bj  plunging  the  instrument 
into  cold  water. 


Fig.  10. 


Fiff.  11. 


Sims's  elevator  (half  size). 


Emmet's  elevator  (half  size). 


Some  sixteen  years  ago,  Dr.  Sims  devised  an  ingenious  instrument 
for  replacing  a  rctroverted  uterus  (Fig.  10).    The  stem-shaped  portion 


THE    ELEVATOR  —  THE    APPLICATOll.  29 

was  introduced  into  tlie  canal,  when,  by  depressing  the  instrument  and 
gently  pushing  it  backwards  into  the  posterior  cul-de-sac,  the  cervix 
was  made  to  pass  under  and  beyond  the  fundus,  and  the  organ  became 
anteverted.  This  was  a  most  important  advance  from  the  old  plan  of 
replacing  the  uterus  with  Simpson's  sound,  a  procedure  always  at- 
tended with  risk,  even  in  the  hands  of  an  expert,  for  the  weight  of 
the  uterus,  at  the  fundus,  rests  on  the  point  of  the  sound,  and  it  is 
always  difficult  to  judge  of  the  amount  of  force  employed,  or  of  the 
existence  of  adhesions.  With  Dr.  Sims's  instrument  the  fundus  is 
not  reached,  the  uterus  rests  on  the  bulb  at  the  base  of  the  stem,  and, 
with  ordinary  precaution,  the  slightest  resistance  can  be  appreciated. 
The  only  objection  to  the  instrument  is  found  in  using  it  in  a  narrow 
vagina,  or  a  shallow  posterior  cul-de-sac,  when  it  cannot  be  Avith- 
drawn  from  the  uterine  canal  without  again  partially  retroverting  the 
organ. 

This  difficulty  led  me  to  have  the  uterine,  or  stem,  portion  divided 
into  three  jointed  segments,  movable  from  the  straight  position  only  in 
a  forward  direction  (Fig.  11).  By  pressure  backward,  the  three 
segments  are  brought  into  line,  and  the  stem  is  as  unyielding  as 
that  in  Dr.  Sims's  instrument.  The  uterus  is  replaced  in  the  same 
manner  as  with  his  instrument,  but  the  joints  allow  the  portion  in  the 
uterine  canal  to  be  withdrawn  without  disturbing  the  cori-ected  posi- 
tion of  the  uterus. 

I  have  for  years  used  Sims's  elevator  for  estimating  the  relation  of 
the  uterus  to  an  abdominal  growth,  A  stylet  runs  through  the  instru- 
ment, and  by  a  spring  in  the  handle  is  made  to  slip  into  a  series  of 
holes  in  the  bulb,  so  that  the  uterine  portion  can  be  locked  at  any 
angle.  When  introduced  into  the  uterus  and  thus  secured,  the  organ 
is  entirely  under  the  control  of  the  operator.  On  moving  the  uterus 
in  any  direction  by  means  of  this  instrument  in  one  hand,  we  are 
able  to  judge  of  its  relation  with  an  abdominal  tumor  by  placing  the 
other  hand  upon  the  abdomen. 

The  applicator  (Fig.  12)  is  designed  for  introducing  medicated  fluids 
within  the  canal,  in  the  treatment  of  uterine  disease,  and  for  arresting 
any  accidental  bleeding  that  may  follow  an  examination.  This  instru- 
ment, as  well  as  the  probe,  should  be  made  of  pure  silver,  and  not  of 
coin  metal,  or  it  will  soon  break  from  a  frequent  changing  of  the  curve. 
As  generally  made  and  sold  in  the  shops  it  is  almost  useless  for  the 
purpose,  as  it  is  too  long,  and,  being  of  the  same  thickness  through- 
out, it  bends  so  readily  upon  itself  that  it  is  difficult  with  it  to  reach 


30 


IXSTETMEXTS    USED    IX    EX  AMI^ATIOXS . 


the  fundus.  It  is  often  made  of  German  silver  to  Tvhich  a  portion  of 
coin  silver  is  ^velded,  but  this  is  objectionable  also,  as  the  tivo  soon 
separate.  The  end  of  the  instrument  is  sometimes 
inserted  for  so  short  a  distance  into  the  handle,  T\"hich 
is  generally  of  vrood,  that  it  is  easily  broken.  It 
should  be  made  from  a  rod  of  silver  about  one-eighth 
of  an  inch  square,  gradually  tapering  to  half  this 
width  and  thickness,  but  not  rounded,  except  near 
the  end.  The  handle  need  not  be  larger  than  that 
of  a  grooved  director,  "which  is  of  sufficient  size  to 
be  grasped  between  the  thumb  and  forefinger,  and 
the  whole  can  be  made  in  one  piece.  When  complete, 
the  instrument  should  be  about  eight  inches  long. 
The  probe  should  be  made  in  the  same  manner,  of 
one  piece,  but  much  lighter,  and  gradually  tapering 
from  the  handle  ;  the  edges  should  be  rounded  ofi"  for 
half  the  lenorth,  and  terminate  in  a  button. 


The  illustration  (Fig.  13)  on  the  next  page  repre- 
sents a  convenient  and  compact  case  made  to  contain 
the  instruments  which  have  been  described,  and 
others  to  be  spoken  of  later.  In  the  middle  com- 
partment are  placed  the  scissors  and  other  instru- 
ments which  would  be  injured  by  being  twisted  in 
the  rolling  or  folding  of  a  case.  Beneath  these  is 
space  for  the  speculum  and  sponge-holders. 


Sponge  tents  are  indispensable  for  dilating  the 
uterine  os  and  cen'ix,  to  detect  the  source  of  a 
hemorrhage,  and  to  ascertain  the  position  and  size 
of  any  growth  within  the  canal.  They  are  also 
very  serviceable  in  the  treatment  of  certain  con- 
ditions which  will  be  referred  to  hereafter.  Their 
use  is  frequently  followed  by  serious  consequences, 
from  the  want'of  proper  care  in  their  preparation, 
Emmet's  applicator.  £j,q^  ^  \^q\^  ^f  judgment  as  to  whcu  the  condition  of 
the  patient  justifies  their  introduction,  and  from  neglect  in  caring  for 
the  patient  afterwards. 

Their  proper  preparation  is  of  sufficient  importance  to  warrant  the 
surgeon  charging  himself  with  that  duty,  and  if  this  be  impossible,  he 
must  delegate  it  only  to  a  competent  and  trustworthy  person.     The 


SPONGE    TENTS, 


31 


sponges  should  be  carefully  selected,  and  of  rather  a  coarse  quality, 
but  free  from  sand  and  shells.  At  first  they  must  be  thoroughly 
washed  with  soap  and  hot  water,  the  impurities  picked  out  as  far  as  pos- 
sible, and  then  exposed  to  the  action  of  the  sun  for  a  day  or  two.    The 


Fisr.  13. 


sponge  is  next  cut  up  into  cone-shaped  pieces  of  different  sizes,  which 
are  trimmed  of  their  inner  edges,  but  as  far  as  possible  the  outer  portion 
of  the  sponge  should  be  preserved,  as  it  makes  a  smoother  surface 
upon  which  to  wind  the  cord.  The  pieces  should  again  be  thoroughly 
washed  in  hot  water  to  which  a  little  of  Squibb' s  impure  carbolic  acid 
has  been  added,  and  again  carefully  picked  over,  to  remove  any  sand 
or  shell  which  can  now  be  easily  felt  in  so  small  a  piece.  The  gum 
Arabic  should  be  of  the  best  quality,  and  the  solution  a  saturated 
one.  An  instrument  with  a  handle,  like  a  straight  awl  (a  broken 
tenaculum  answers  very  well  for  the  purpose,  but  it  should  be  a  little 
longer  than  the  sponge),  is  passed  through  the  sponge,  Avhich  is  then 
dipped  into  the  solution  and  wrapped.  The  cord  should  be  a  strong 
one,  but  not  large,  and  the  wrapping  must  be  begun  by  two  half  hitches 
at  the  larger  end,  so  that  it  will  not  slip.  The  tighter  the  cord  is 
drawn  the  better,  and  it  should  be  served  evenly  throughout,  and  at 
the  end  finished  by  half  hitches.  Not  only  is  the  sponge  to  be  com- 
pressed in  its  diameter,  but  also  shortened  as  much  as  possible  by 
crowding  it  down  on  the  stafi"  as  it  is  being  wrapped.     It  is  very  de- 


32 


IXSTRUMEXTS    USED    IN    EXAMINATIONS. 


Fig.  14. 


siraUe  to  have  the  tents  made  in  this  manner,  so  that  they  may 
expand  in  length  and  advance  heyond  the  point  to  which  they  are 
introduced.  When  the  cord  has  been  secured,  the  staff  is  with- 
drawn, and  the  tents  dried  rapidly  before  a  hot  fire  or  in  the  sun. 
When  nearly  dry,  but  still  pliant,  a  number  of  them  should  be  bent  in 
different  curves,  and  allowed  to  harden  in  the  form  given  them.  After 
they  have  become  thoroughly  dry  the  cord  may  be  removed,  and  the 
tents  are  then  ready  for  use.  They  require  no  wax,  and  are  preferable 
without  it,  since  the  coating  occupies  a  space  which  otherwise  would 
admit  a  larger  tent.     The  roughened  surface  left  after  removing  the 

cord  is  an  advantage  in  prevent- 
ing the  tent  from  slipping  out, 
and  it  does  not  injure  the  mucous 
membrane  since  it  softens  as 
soon  as  it  comes  in  contact  with 
any  moisture. 

A  great  deal  of  irritation, 
and  frequently  inflammation,  is 
caused  by  forcing  a  straight 
tent  into  a  curved  canal.  It  is, 
therefore,  a  great  advantage, 
and  one  which  I  have  appre- 
ciated for  ten  years  or  more,  to 
have  the  tents  conform  to  the 
curve  of  the  canal.  This  is 
ascertained  by  means  of  the 
probe,  bent  and  carefully  intro- 
duced until  the  exact  curve  is 
obtained.  If  the  proper  tent 
be  then  selected,  it  can  be  intro- 
duced without  difficulty,  and 
will  cause  but  little  irritation 
afterwards. 

Fig.  14  represents  a  sponge 
dilator  which  I  designed  in 
1870,  and  I  have  found  it  use- 
ful for  making  a  final  dilata- 
tion of  the  uterine  canal  previous  to  performing  an  operation. 
Through  a  disk  of  hard  rubber  passes  a  brass  tube,  which  is  per- 
forated  by  a  number   of  small  holes  at  the  upper  portion,  and  is 


Emmet's  sponge  dilator. 


THE    SPONGE    DILATOR.  33 

open  at  each  extremity.  This  tube  is  passed  through  the  centre  of  a 
sponge  tent  of  suitable  size,  the  tent  is  then  covered  by  a  thin  India- 
rubber  cot  or  bag,  and  its  mouth  stretched  over  the  edges  of  the  disk. 
The  free  edge  of  the  cot  which  has  been  drawn  over  the  disk  is  then 
secured,  compressed  between  the  under  side  of  the  disk  and  the  brass 
plate  A  B  on  screwing  up  the  latter  sufficiently.  The  brass  disk  A  B 
has  attached  to  it  on  side  at  B,  a  knob  which  can  be  grasped  by  a 
pair  of  forceps,  the  limbs  of  which  are  closed  by  sliding  forward  the 
canula  E,  When  the  knob  B  is  held  by  the  forceps,  a  ball-and-socket 
joint  is  formed,  Avhich  will  admit  of  any  motion  within  the  radius  of  a 
sphere.  To  the  bulb  at  C  is  attached  a  piece  of  India-rubber  tubing, 
a  foot  or  more  in  length,  through  which  water  is  introduced  for  swell- 
ing up  the  tent,  and  at  the  end  of  the  tube  is  a  stopcock.  To  the 
other  side  of  the  stopcock  a  Davidson's  syringe  may  be  joined,  or 
what  I  have  found  to  answer  better,  a  thin  India-rubber  bag,  such 
as  are  used  for  pessaries,  with  tube  and  stopcock.  The  dilator  is 
introduced  by  steadying  the  cervix  with  a  tenaculum  in  one  hand,  and 
by  holding  the  forceps  and  tubing  in  the  other  the  proper  direction 
can  be  given  to  the  instrument.  When  it  has  been  introduced  within 
the  canal  to  the  proper  depth,  a  small  amount  of  water  is  to  be  thrown 
in  before  removing  the  forceps.  As  the  tube  occupying  the  centre  of 
the  sponge  is  open  at  its  extremity  and  its  sides  perforated,  the  water 
will  make  its  exit  at  the  upper  portion,  and  dilatation  will  extend  from 
above  downward,  so  that  the  instrument  cannot  slip  out.  Enough 
of  the  sponge  is  dilated  in  a  few  moments  for  the  purpose  of  retention, 
so  that  the  forceps  may  then  be  removed  by  sliding  back  the  canula. 
I  direct  the  patient  to  lie  in  bed  on  her  back,  and  to  place  on  the 
abdomen  the  air  bag,  which  has  been  filled  with  water,  from  which  a 
sufficient  supply  to  fully  dilate  the  sponge  is  made  to  flow  by  occa- 
sionally compressing  the  bag  with  the  hand. 

I  generally  leave  the  dilator  in  place  for  some  twelve  hours,  unless 
there  should  exist  some  special  reason  for  more  rapid  dilatation. 
The  instrument  is  easily  withdrawn  by  placing  the  patient  on  her  back, 
removing  the  bag,  and  turning  the  stopcock  for  the  escape  of  water 
from  the  sponge.  The  forceps  can  be  passed  along  the  index  finger 
into  the  vagina  and  attached  to  the  instrument,  when  it  can  be  with- 
drawn, guarding  against  displacing  the  uterus  by  holding  the  finger 
against  the  cervix. 

The  chief  advantage  of  this  dilator  is  that  it  greatly  reduces 
the  risk  of  blood-poisoning,  and  if  we  could  dispense  with  the  un- 
protected sponge  in  the  first  instance  this  danger  would  be  entirely 


34  INSTRUMENTS    USED    IN    EXAMINATIONS. 

obviated.  Fortunately,  when  this  does  occur,  ifc  is  seldom  from  the 
use  of  a  single  tent,  and,  if  the  precaution  be  taken,  which  I  always 
insist  upon,  to  wash  out  the  canal  tlioroughly  whenever  a  tent  is  re- 
moved, Ave  will  greatly  lessen  the  risk.  It  is  also  a  great  advantage 
gained  from  the  use  of  the  dilator  that  the  mucous  membrane  is  not 
injured,  and  consequently  we  have  no  bleeding  from  the  canal  when  it 
is  removed. 

The  disadvantages  are  that  we  can  seldom  dilate  to  the  same  extent 
as  can  be  done  by  the  tent  alone.  The  resistance  offered  by  the 
uterine  wall  will  yield  to  the  steady  pressure  of  the  sponge,  but  the 
elasticity  of  the  India-rubber  bag  is  persistent,  and  will  to  some  extent 
counteract  the  force  of  the  sponge.  Consequently  we  are  obliged  to 
use  a  cot  much  larger  than  the  sponge,  which  will  occupy  an  additional 
space,  and  therefore  makes  it  necessary  that  the  canal  should  be 
partially  dilated  before  the  dilator  can  be  introduced. 

On  the  other  hand,  this  dilator  has  the  advantage  that  the  force  can- 
not be  concentrated  at  any  one  point,  but  must  be  exerted  throughout, 
as  the  sponge  gradually  dilates.  I  have  used  the  instrument  several 
times  for  rapid  dilatation,  and  it  answers  the  purpose,  but  unless  there 
should  be  a  necessity  for  doing  so,  the  more  gradual  process  is  to  be 
recommended,  as  attended  with  less  risk  in  surgical  procedures ;  but 
the  contrary  is  true  in  obstetrical  practice.  For  rapid  dilatation, 
however,  it  has  no  advantage  over  any  other  instrument  of  the  kind, 
as  at  first  the  water  escapes  outside  of  the  sponge  when  rapidly  thrown 
in,  and  becomes  the  dilating  power,  but  as  soon  as  the  sponge  has  had 
time  to  expand,  it  absorbs  the  water  and  the  pressure  then  becomes 
uniform.  With  other  dilators,  where  water  is  the  medium  employed, 
the  power  is  much  greater,  but  a  large  portion  of  the  force  is  always 
lost  in  the  direction  from  the  os  to  the  vagina,  and  if  the  parts  do 
not  yield  readily  above,  the  bag  becomes  ruptured  below.  This  is 
the  chief  objection  to  Barnes's  dilator ;  a  large  portion  of  the  bag 
becomes  expanded  in  the  vagina  and  will  frequently  burst  at  this 
point,  unless  there  is  sufficient  space  in  the  uterine  cavity  for  its  ex- 
pansion in  that  direction. 

This  difficulty  I  have  overcome  by  the  design  of  an  instrument  which 
can  be  introduced  with  the  greatest  facility.  It  can,  moreover,  be 
held  in  position  until  dilated  sufficiently  above  to  keep  it  from  slipping 
out  of  the  canal. 

The  small  opening  at  the  end  of  an  India-rubber  cot  is  stretched 
over  a  hard  rubber  button,  and  held  from  slipping  by  being  compressed 


THE    WATER    DILATOR. 


35 


between  it  and  a  disk,  Avhich  is  screwed  into  position  as  shown  in 
Fig.  15. 

In  fact,  the  same  arrangement  will  answer  for  both  purposes  if  the 
perforated  tube  can  be  removed  on  which  the  sponge  tent  is  held. 
This  cot  is  entered  at  the  side,  and  below,  by  a  tube  closed  at  the 
upper  end,  Avhich  lies  full  in  its  cavity,  but  is  long  enough  to  reach 

Fis.  15. 


Emmet's  water  dilator. 


the  end  of  the  dilator.  Through  this  tube  a  copper  sound  is  to  be  in- 
troduced to  the  end,  for  the  purpose  of  carrying  the  top  of  the  bag  to 
the  fundus.  If  necessary  to  facilitate  its  introduction,  the  sound  can 
be  bent  in  any  direction,  and  the  bag  wall,  of  course,  conform  to  the 
same. 

A  piece  of  tubing  of  sufficient  length  to  project  beyond  the  vagina 


36  INSTRUMENTS    USED    IN    EXAMINATIONS. 

is  attached  to  the  button,  and  the  nozzle  of  a  Davidson's  syringe  is  to 
he  inserted  into  the  other  end.  The  top  of  the  bag  is  to  be  held  at 
the  fundus  by  means  of  the  sound,  throughout  the  operation,  or  until 
a  sufficient  quantity  of  water  has  been  thrown  in  to  dilate  it  enough 
to  be  retained. 

On  the  tubing  is  shown  a  simple  contrivance  by  which  its  sides  can 
be  firmly  compressed  by  turning  up  the  little  tongue  of  metal.  After 
fully  distending  the  bag,  and  then  compressing  the  sides  of  the  tube 
by  this  cheap  substitute  for  a  stopcock,  the  dilating  force  can  be 
exerted  continuously  with  but  little  loss  of  power.  After  an  interval 
of  a  few  moments,  more  water  can  be  thrown  in,  and  by  degrees,  with 
a  little  tact,  the  uterus  can  be  fully  dilated  by  this  means  as  rapidly, 
if  not  even  with  more  facility  than  with  any  other  dilator.  The  great 
objection  to  this,  in  common  with  all  soft  rubber  instruments,  is  that, 
unless  recently  made,  they  cannot  be  relied  upon  to  stand  a  continu- 
ous strain  without  bursting.  Yet  this  will  bear  far  more  than  any 
other,  since  it  is  supported  so  uniformly  by  the  uterine  walls.  This  in- 
strument might  be  made  of  larger  sizes  for  obstetrical  purposes ;  and 
would  answer  exceedingly  Avell  for  bringing  on  labor  by  rapid  dilata- 
tion of  the  OS  uteri. 

I  have  found  it  often  most  serviceable  for  arresting  hemorrhage, 
particularly  when  due  to  soft  growths,  or  to  some  diseased  condition  of 
the  mucous  membrane.  It  is  of  great  value  after  a  tent  has  been  used, 
to  increase  the  dilatation  at  the  time  of  operating  for  the  removal  of 
some  intra-uterine  tumor.  For  the  purpose  of  making  an  exploration 
of  the  canal,  ten  or  fifteen  minutes  will  often  be  siifficient.  But  such 
rapid  dilatation  should  never  be  employed  unless  in  some  urgent  case. 
When  a  tent  has  been  first  used  if  pregnancy  exists,  or  at  the  time  of 
hemorrhage,  there  will  be  less  risk  from  rapid  dilatation.  Under 
other  circumstances,  this  procedure  is  always  attended  with  the  danger 
of  exciting  inflammation. 

Rules  for  the  Use  of  Sponge  Tents. — Before  introducing  a  sponge 
tent  for  the  purpose  of  dilating  the  uterine  canal,  it  is  well  to  have  the 
bowels  moved,  and  to  be  satisfied  that  the  patient  is  not  suflFering  from 
the  effects  of  recent  cold  or  any  other  special  disorder.  But  above 
all,  a  tent  should  never  be  passed  into  the  canal  if  there  has  been  an 
attack  of  cellulitis  so  recent  that  a  vestige  of  thickening  remains,  or 
if  the  slightest  tenderness  on  pressure  can  be  detected  by  the  finger 
in  any  part  of  the  vagina. 

The  operator  who  does  not  inform  himself  fully  as  to  the  condition 


THE    USE    OF    SPONGE    TENTS.  37 

of  the  patient  in  regard  to  any  old  cellulitis  that  may  have  existed, 
and  as  to  the  fitness  of  the  patient  for  the  operation,  is  criminal  in  his 
neglect,  since,  ^^■ith  all  the  care  that  a  conscientious  man  may  be  able 
to  exercise,  bad  results  will  sometimes  follow  the  use  of  this  agent. 

When  the  uterine  canal  is  curved,  a  tent  must  be  selected,  as  I  have 
already  shown,  of  a  similar  curve ;  and  it  is  better  to  use  several  small 
tents  than  a  single  very  large  one.  Select  a  size  which  can  be  easily 
inserted,  and  around  this  several  thinner  ones  can- be  passed  into  the 
canal.  Each  tent  should  have  a  string  attached  by  a  double  half 
hitch  to  its  base,  and  before  its  introduction,  it  should  be  dipped  into 
glycerine  as  it  will  expand  rapidly  from  the  moisture  furnished  by 
this  agent,  Avhich  is,  moreover,  a  disinfectant.  I  make  it  a  rule 
to  place  the  patient  in  bed  immediately,  applying  heat  by  some  con- 
venient means  to  the  feet,  and,  if  the  weather  is  cool,  the  sheets  should 
be  previously  warmed.  I  never  allow  a  patient,  under  any  circum- 
stances, to  get  out  of  bed,  so  the  bladder  must  be  emptied  by  means 
of  a  catheter,  or  into  a  bed-pan.  The  greatest  care  must  be  exercised 
to  guard  againt  exposure  to  cold ;  she  must  be  kept  quiet,  and  an 
enema  of  some  preparation  of  opium  administered,  should  there  be 
pain  enough  to  call  for  an  anodyne.  When  the  pain  is  severe,  and  is 
not  relieved  by  the  opiate,  or  if  a  sensation  of  chilliness  is  experienced, 
it  is  better  to  remove  the  tent,  and  make  another  attempt  at  dilatation 
at  some  future  time.  The  nurse  is  always  directed  to  give  a  large 
vaginal  injection  of  wann  water  night  and  morning,  with  the  addition 
of  a  little  carbolic  acid,  if  there  should  be  much  discharge.  A  tent  is 
seldom  allowed  to  remain  in  the  uterine  canal  longer  than  twenty 
hours  when  used  for  diagnostic  purposes. 

While  the  patient  lies  upon  the  back  the  tent  can  be  removed  by 
holding  the  string  in  one  hand,  while  pressure  is  made  downward  and 
backward  with  the  index  finger  of  the  other  hand  against  that  portion 
of  it  nearest  the  cervix.  If,  however,  the  tent  is  a  large  one,  it  is 
best  to  bring  the  cervix  into  view  with  Sims's  speculum,  and  Avith  a 
pair  of  strong  forceps  twist  the  tent  upon  itself  until  it  becomes  loos- 
ened through  reduction  of  its  diameter.  It  can  now  be  withdrawn, 
but  before  it  is  entirely  removed  from  the  canal,  reverse  the  twist  that 
the  sponge  in  expanding  may  again  take  up  the  fluid  which  was  ex- 
pressed from  it. 

To  facilitate  a  diagnosis  of  the  condition  within  the  uterine  cavity, 
it  will  be  necessary  to  place  the  patient  on  her  back,  with  the  lower 
extremities  drawn  up.  Then,  as  the  index  finger  of  one  hand  is 
passed  within  the  uterus,  the  other  hand  is  to  be  placed  over  the 


38  INSTRUMENTS    USED    IX    EXAMINATIONS. 

abdomen  to  steady  the  organ,  and  at  the  same  time  to  gently  press 
it  low  enough  into  the  pelvis  for  the  finger  to  reach  the  fundus,  if  the 
uterus  is  not  too  much  enlarged.  After  the  examination  has  been 
made,  the  uterus  must  again  be  lifted  by  the  finger  to  its  proper  place 
in  the  pelvis,  and  the  cavity  well  washed  out  with  warm  water.  This 
can  be  done  with  the  patient  lying  on  her  back,  a  bed-pan  being  placed 
under  her,  and  the  nozzle  of  Davidson's  syringe  passed  into  the  uterine 
cavity ;  or,  the  patient  may  be  placed  on  the  left  side,  the  speculum 
introduced,  and  the  water  thrown  in  and  withdrawn  by  means  of  the 
long  curved-nozzle  syringe,  shown  in  Fig.  9.  If  the  uterus  has  been 
well  dilated,  the  best  position  for  the  purpose  is  on  the  back,  as  its 
cavity  can  then  be  thoroughly  washed  out.  But  to  facilitate  the 
escape  of  water  and  clots  from  the  uterine  canal,  the  index  finger  of 
one  hand  should  be  inserted  just  within  the  os,  and  the  perineum  kept 
simultaneously  well  retracted  by  pressure  with  the  back  of  the  hand. 
After  the  injection  has  been  given,  the  dilator  or  another  tent  can 
be  introduced  if  necessary,  the  patient  being  again  placed  in  bed  and 
treated  in  the  same  manner  as  during  the  first  dilatation.  If  the 
uterus  is  not  to  be  again  dilated,  I  make  it  a  rule  to  apply  Churchill's 
strong  tincture  of  iodine  freely  to  the  cavity,  either  by  means  of  the 
applicator  or  by  injecting  a  small  quantity  to  the  fundus  from  a  long- 
nozzled  syringe.  Theeifect  of  the  iodine  is  to  cause  rapid  contraction 
of  the  uterus,  and  it  is  also  a  good  disinfectant ;  afterwards,  the  patient 
should  be  replaced  in  bed,  and  kept  quiet  until  the  next  day. 

There  are  many  in  the  profession  who  would  ridicule  the  necessity 
for  any  such  caution  as  I  have  advised,  but  I  have  had  some  unhappy 
experience  in  times  past,  which  might  have  been  guarded  against  with 
my  present  knowledge.  For  years  I  have  followed  ray  present  plan, 
and  in  no  instance  will  I  introduce  a  tent  in  my  ofiice  and  allow  the 
patient  to  return  home.  As  a  rule,  I  have  insisted  upon  the  patient 
remaining  for  the  time  in  my  private  hospital,  and  have  only  made 
the  exception  to  treat  a  patient  in  her  own  house  when  I  have  felt 
satisfied  that  my  directions  would  be  fully  carried  out.  Every  year's 
experience  has  but  the  more  confirmed  me  in  the  correctness  of  my 
views. 

The  sponge  tent  is  not  only  needed  for  dilating  the  canal,  that  we 
may  be  able  to  form  a  diagnosis,  but  is  a  most  valual)le  aid  in  treating 
certain  fornis  of  uterine  disease,  as  will  be  shown  hereafter.  Almost 
every  one  in  practice  has  at  some  time  experienced  the  bad  effects  and 
even  disastrous  results  following  the  indiscriminate  use  of  sponge 
tents;  more  care,  therefore,  must  be  exercised  by  the  profession,  or 


THE    USE    OF    SPONGE    TENTS.  39 

a  valuable  means  will  eventually  fall  into  oblo([uy.  Sometimes,  from 
a  comparatively  slight  provocation,  an  attack  of  cellulitis  or  blood- 
poisoning  may  occur;  at  others,  again,  the  degree  of  tolerance  shown 
is  most  remarkable. 

Some  ten  years  ago,  a  fashionable  lady  in  this  city  was  under  my 
care  for  frequent  hemorrhage.     The  uterus  was  four  inches  deep.     It 
became  necessary  to  dilate  the  uterus,  and  as  she  resided  quite  near 
me,  she  came  to  my  office  for  the  purpose  of  having  me  introduce  a 
tent,  one  about  three  inches  in  length  being  used.     Feeling  anxious, 
I  accompanied  her  to  the  carriage,  impressing  on  her  the  necessity 
for  carrying  out  my  directions  by  remaining  quietly  in  bed,  and  I  saw 
her  drive  in  the  direction  of  her  residence.     As  soon  as  my  back  was 
turned  she  directed  her  coachman  to  drive  to  Stewai't's,  where  she 
purchased  the  materials  for  a  dress ;  then  went  to  a  mantua-maker, 
stood  for  a  long  time  to  have  it  fitted;    returned  home  in  time  to 
dress  for  a  dinner-party,  and  afterwards  went  to  a  ball,  where  she 
danced  until  a  late  hour.     On  the  following  day,  after  my  office  hours, 
I  called  at  her  house,  and  found  that  she  had  gone  out  early.     I 
called  frequently,  and  finally  wrote  requesting  that  she  would  appoint 
some  hour  when  I  could  see  her,  but,  in  despair,  I  was  obliged  to 
await  her  pleasure.     Fortunately,  no  bad  results  followed,  but  I  was 
unable  to  see  her  until  the  fifth  day,  when  she  .called  at  my  office  for 
the  purpose  of  having  "the  nasty  thing"  removed.     I  was  thankful  to 
be  allowed  the  privilege  of  removing  it,  but  I  informed  her  that  she 
would  have  to  seek  further  treatment  elsewhere.     She  did  not  need 
it,  however,  as  she  was  afterwards  cured,  for  the  granulations  which 
had  existed  in  the  canal  were  destroyed  by  the  long  pressvire  of  the 
tent,  and,  from  the  continued  drainage  and  stimulus  exerted  by  its 
presence,  the  uterus  returned  rapidly  to  its  natural  size,  a  result  which 
she  certainly  did  not  merit.     Other  agents  have  been  employed  for  the 
purpose  of  dilating  the  uterine  canal,  but  none  possess  the  same  capacity 
as  the  compressed  sponge,  and  are  consequently  of  but  little  value  for 
surgical  purposes  or  as  aids  in  diagnosis.    The  laminaria  digitata,  or  sea- 
tangle,  it  was  thought  would  supersede  the  use  of  the  sponge,  and  would 
lessen  the  risk  from  blood-poisoning ;  but  apart  from  its  limited  dilating 
capacity  there  are  other  objections  to  its  use.     It  has  been  found  to 
expand  unequally  throughout  its  length,  so  that  it  may  dilate  fully  at 
one  or  each  end,  and  consequently  become  exceedingly  difficult  of 
removal.     It  will  also  cause  frequently  more  irritation  than  the  tent, 
from  being  stifi"  and  unyielding,  and  as  it  expands  much  slower  it 
is  more  difficult  to  keep  it  from  slipping  out  of  the  canal.     When  the 


40  INSTRUMENTS    USED    IN    EXAMINATIONS. 

OS  is  contracted  and  so  small  that  a  tent  of  proper  calibre  would  not 
be  firm  enough  to  pass,  a  short  section  of  laminaria  is  found  useful  to 
open  the  canal  of  the  cervix  for  the  subsequent  rece^Dtion  of  the  tent. 

Dr.  G.  E.  Sussdorff,  of  New  York,  has  recommended,^  as  a  substi- 
tute for  the  sponge  tent,  the  root  of  the  tupelo  tree,  or  the  njssa 
aquatica,  which  is  found  in  the  swamps  of  the  Southern  States.  This 
agent  is  far  superior  to  the  laminaria,  but  has  not  the  dilating  power 
of  the  sponge  tent,  yet  it  is  a  very  valuable  acquisition. 

Dr.  Goldsmith,  of  Atlanta,  Georgia,  has  employed  tents  of  the 
compressed  pith  of  the  cornstalk  for  the  purpose  of  dilatation.  Un- 
fortunately, this  substance  does  not  possess  the  dilating  capacity  of 
the  sponge,  but  I  have  found  it  very  useful  for  treating  certain  condi- 
tions of  the  uterus,  to  be  referred  to  hereafter. 

1  The  Medical  Kecord,  New  York,  July  14,  1877. 


STiRGICAL    INSTRUMENTS    AND    APPLIANCES, 


41 


CHAPTER   III. 

SURGICAL  INSTRUMENTS  AND  APPLIANCES. 

Scissors  of  various  curves — Ball-and-socket  knife — Needles — Sims's  needle-holder 
— Emmet's  needle  forceps — Sims's  feeder — Twisting  forceps — Sims's  shield — 
Double  tenaculum — Sims's  blunt  hook — Counter-pressure  hook — Silver  wire — 
Mode  of  freshening  surfaces,  before  the  introduction  of  sutures — Silver  sutures, 
and  mode  of  introduction. 

Mode  of  administering  vaginal  injections  of  hot  water — Foster's  vaginal  syringe 
— Vaginal  tampon  ;  its  use  and  mode  of  apijlication. 

Seisso7'8. — For  some  fourteen  years  I  have  used  scissors  almost 
exclusively,  and  have  been  instrumental  in  their  introduction  for  the 
various  operations  about  the  female  organs  of  generation,  in  preference 
to  the  knife. 

With  the  scissors  a  surface  can  be  thoroughly  freshened  in  less 
time,  and  with  less  bleeding,  from  which  latter  cause  much  delay  or 
an  abandonment  of  the  operation  was  formerly  of  frequent  occurrence, 
when  the  knife  was  used. 

I  make  use  of  four  pairs  of  scissors,  two  of  which  have  each  a  large 
curve  to  the  blades,  right  and  left,  and  two  a  smaller  curve,  also  right 
and  left.     Those  represented  in  Fig.  16  are  of  a  lesser  curve  and 

Fig.  16. 


Emmet's  scissors 


are  the  most  needed  for  general  use.  The  other  pair  (Fig.  IT)  is 
invaluable,  when  properly  made,  for  denuding  a  surface  high  up  in 
the  vagina,  or  running  across  the  axis  of  the  passage.  It  is  almost 
impossible  to  represent  these    scissors  by  a  diagram ;  the  dip  of  the 


42 


SURGICAL    IXSTRUMENTS    AND    APPLIAXCES. 


blades  from  the  handles  is  about  thirty  degrees,  and  their  curve  a 
quarter  of  a  circle,  with  the  extremity,  or  cutting  surface,  somewhat 
prolonged  at  a  tangent.  The  blades  at  the  joint  are  vertical,  but  they 
gradually  twist  upon  themselves  until  they  cross  each  other  at  their 


FiR.  17. 


Emmet's  scissors. 


extremities  in  the  horizontal.  Some  idea  of  the  double  curve  given 
the  smaller  scissors  may  be  obtained  by  resting  the  forearm  on  a  table, 
with  the  hand  rotated  outward  so  that  the  backs  of  the  fingers  will 
also  rest  upon  the  table  when  semiflexed.  A  large  number  of  these 
scissors  sold  by  the  instrument-makers  are  worthless,  ha\dng  no  re- 
semblance to  the  proper  shape.  ^Necessarily,  each  blade  represents 
a  diiferent  arc  of  a  circle,  and  they  must  be  so  accurately  adjusted 
that  their  cutting  edges  will  not  come  in  contact  except  near  the 
points.  Even  where  the  shape  has  been  preserved,  the  instrument 
is  found  frequently  to  be  of  little  value,  for,  owing  to  bad  workman- 
ship, the  blades  cross  each  other  and  come  in  contact  from  the  heel  to 
the  point.  The  result  is,  that  the  joint  becomes  strained  from  the 
first  use,  and  it  is  impossible  with  them  to  remove  a  continuous  strip 

Fig.  18. 


Emmet's  scissors. 


in  consequence  of  the  blades  being  so  close  together  that  there  is  not 
room  between  them  for  the  tissues  to  pass,  and  hence  only  a  single 
bite  can  be  removed  at  a  time. 

The  remaining  pair  of  scissors  to  be  described  is  shown  in  Fig.  18. 


THE    BALL-AND-SOCKET    KNIFE — NEEDLES. 


43 


They  arc  used  chiefly  for  dividing  cicatricial  bands  in  the  vagina,  for 
paring  flaps,  and  for  dividing  the  cervix  backwards.  These  scissors  are 
blunt  pointed,  bent  at  an  angle,  and  not  curved  to  either  side. 

Occasionally  a  knife  is  necessary  at  some  inaccessible  point,  and 
the   ball-and-socket   knife.  Fig.  19,  will  be  found   useful.     Sixteen 

Fig.  19. 


Emmet's  "ball-and-socket  kuife. 

years  ago,  Dr.  Sims  introduced  a  knife,  for  dividing  the  cervix 
laterally,  which  had  a  single  joint,  so  that  the  blade  could  only  be 
moved  as  the  radius  of  a  single  circle  and  was  locked  by  a  screw  in 
the  joint.  About  two  years  afterwards,  I  devised  the  above  instru- 
ment, of  which  the  handles  are  represented  in  the  figure  at  half  size, 
and  the  blade  without  reduction.  The  shape  and  size  of  the  blade  are 
like  that  in  Dr.  Sims's  instrument,  but  the  joint  being  a  ball-and-socket 
the  blade  can  be  placed  in  any  position,  and  firmly  secured  by  lock- 
ing the  handles. 

Needles. — The  round  needles  have  the  advantage  of  making  only  a 
punctured  wound,  which  will  be  filled  up  by  the  suture.  I  w^as  the  first 
to  advocate  their  use  for  all  operations  about  the  vagina.  The  needles 
in  general  use,  which  are  spear-pointed  or  triangular  in  shape,  with 
a  cutting  eye  and  many  times  the  diameter  of  the  wire,  frequently 
cause,  in  vascular  tissue,  a  troublesome  oozing  after  the  sutures  have 
been  secured.  Sometimes  also  a  small  fistula  will  remain  along  the 
track  if,  by  chance,  the  course  of  the  suture  is  too  close  to  the 
bladder. 


The  needles  I  generally  use  are  from  one- half  to  three-quarters 
of  an  inch  in  length  and  round,  with  a  slight  curve  near  their  point, 


44 


SUEaiCAL    IXSTRUMEXTS    AXD    APPLIAXCES, 


thickest  at  the  eye,  which  is  counter-sunk  to  receive  the  thread.  The 
smallest  sized  needle  is  used  for  fistula  in  the  bladder  or  rectum,  and 
for  other  operations  in  the  vagina.  The  next  size  answers  Lest  for 
closing  lacerations  in  the  cervix.  The  largest  one  is  an  ordinary 
sewing  needle,  of  a  large  size,  thick  and  strong,  and  with  a  large  eye 


Fi-.  20. 


Fig.  21. 


Fio-.  22. 


SHEPflRD&DUaLEr 


RC&  DUCLEV 


Emmet's  needles. 


deeply  counter-sunk.  This  needle  I  use  for  closing  a  lacerated  peri- 
neum, and  the  abdominal  walls  after  ovariotomy.  When  the  tissues 
are  dense  and  cicatricial,  as  frequently  found  about  the  cer\dx,  it  is 
often  exceedingly  difficult  to  introduce  the  round  needle.  But  when 
in  this  condition  they  are  less  vascular,  and,  consequently,  the  use  of  the 
round  needle  is  not  so  necessary.  With  this  condition  I  frequently  use 
the  lance-pointed  needle  (Fig.  22),  which  is  very  easy  of  introduction; 
but  when  the  tissues  are  soft  and  vascular  the  round  needle  should  be 
used.     The   needle-forceps.   Fig.    23,  first  introduced  by  Dr.   Sims, 

Fig.  23. 


Sims's  needle-holder. 

are  unequalled  for  their  firm  grasp  and  the  ease  with  which  they  thrust 
the  needle  through  the  tissues  at  any  angle.  But  I  have  had  an  instru- 
ment made  with  shorter  jaws  (Fig.  24),  which  gives  still  gi'eater  facility 
for  introducing  the  needle.  The  handles  are  rough  and  flattened,  so 
that  they  can  be  fii*mly  grasped  in  the  palm  of  the  hand,  and  a  spring 
is  placed  between  them,  so  that  the  needle  can  be  freed  as  soon  as  the 
pressure  of  the  hand  is  relaxed.  One  jaw  should  be  deeply  serrated 
and  the  other  lined  with  a  plate  of  copper,  by  which  means  the  eye 


THE  FEEDER TWISTING  FORCEPS. 


45 


of  the  needle  is  less  likely  to  be  crushed  than  it  would  be  between 
two  rough  steel  surfaces. 

The  "feeder"  (Fig.  25)  is  a  shallow  forked  instrument,  devised  by 
Dr.  Sims,  and  is  very  useful  to  facilitate  the  passage  of  the  suture 


Tin:.  24. 


Emmet's  needle-forceps. 


when  introduced  in  such  a  direction  that  it  would  cut  into  the  tissues 
if  traction  had  to  be  made  at  a  sharp  angle  to  its  course. 


Fi£.  25. 


Sims's  "  feeder.' 


A  pair  of  good  dressing  forceps  will  answer  for  securing  the  Avire 
to  the  silk  loop  by  which  the  metallic  suture  is  to  be  introduced,  but 
I  use  an  instrument  like  the  needle-forceps  (Fig.  24).  A  short  angle 
of  the  wire  is  to  be  hooked  into  the  loop,  flattened  by  the  forceps, 
and  twisted  once  or  twice  on  itself. 

The  twisting  forceps  I  have  modified  from  the  shape  first  used  by 


Fig.  26. 


Einmet'.s  twisting  forceps. 

Dr.  Sims,  making  the  jaws  quite  straight,  and  changing  the  mecha- 
nism by  which  the  instrument  is  closed. 

Sims's  shield,  Fig.  27,  is  used  for  steadying  the  sutures  and  as  the 
guide  to  the  proper  point  at  which  the  wires  should  be  twisted.     This 


46  SURGICAL    INSTRUMENTS    AND    APPLIANCES. 

Fig.  27. 


Fis:.  28. 


<r 


Sims's  shield. 

instrument  was  formerly  made  of  steel,  but 
I  found  it  more  useful  to  have  it  constructed 
in  one  piece  of  copper,  and  silver-plated. 
When  made  of  copper  it  can  he  bent  at 
anj  angle,  so  as  to  rest  flat  on  the  surface 
through  which  the  sutures  have  been  passed. 
The  instrument  sold  is  seldom  properly  made, 
for  the  edge,  at  the  bottom  of  the  slit,  over 
which  the  wire  is  to  be  twisted,  is  left  too  thick. 
It  is  necessary  that  this  surface  should  have  a 
thin  edge,  or  the  sutures  cannot  be  twisted  up 
to  the  proper  point. 

The  double  tenaculum,  Fig.  28,  is  used  for 
operations  about  the  cervix,  for  steadying  the 
uterus  when  making  applications  within  the 
canal,  and  when  operating  within  the  uterine 
cavity.  It  is  to  be  held  in  the  left  hand,  and 
on  depressing  the  thumb  piece  at  A  the  tenacula 
are  made  to  separate,  by  which  the  parts  are 
put  on  the  stretch.  They  are  brought  together 
again  by  drawing  back,  with  the  index  finger, 
the  ratchet  bar  at  B. 

The  blunt  hook  was  used  by  Dr.  Sims  for  the 
purpose  of  detecting  small  openings,  and  is,  in 

Fig.  29. 


Sims's  blunt  hook. 


Emmet's  double  tenaculum. 


fact,  a  steel  probe.    Fig.  30,  which  I  had  made, 
may  answer  the  same  purpose,  but  its  chief  use 
is  for  counter-pressure  as  the  point  of  the  needle 
is  escaping  from  the  tissues.     A  pointed  tenaculum  is  generally  used 


SILVER    SUTURES.  47 


for  this  purpose,  but,  being  so  slight,  it  is  easily  broken  or  bent  out 
of  shape.  The  whole  insti'ument  should  be  made  in  one  piece  of 
hardened  steel,  and  of  a  size  too  large  to  bend  or  break. 


Fi-.  3U. 


St-IEPSHIB  aOUDLEY  ^ - 


Emmet's  counter-pressure  hook. 

3Iode  of  Freshening  Sui'faces  before  the  Introduction  of  Sutures. 
— When  two  surfaces  are  to  be  united  by  sutures,  they  should  always 
be  denuded  to  an  equal  extent,  so  that  no  portion  of  the  line,  when 
brought  together,  Avill  be  left  to  heal  by  granulation.  If  the  parts 
are  free  from  cicatricial  tissue,  and  are  freshened  to  a  broad,  smooth, 
uniform  surface,  and  if  the  edges  are  accurately  approximated,  without 
tension,  and  the  sutures  do  not  cause  sti-angulation,  from  being  twisted 
too  tight,  we  will  usually  obtain  union  by  the  first  intention.  It  should 
be  our  object  to  secure  as  near  an  approximation  as  possible  to  this 
form  of  healing  in  all  operations  about  the  vagina,  since  any  surface 
left  to  heal  by  granulation  becomes  more  or  less  cicatricial,  and  will 
contract  afterwards.  In  denuding  a  surface,  it  is  better  always  to 
begin  at  the  lowest  point  and  pass  upwards,  for  in  this  way  we  prevent 
the  flowing  of  blood  over  the  surface  as  the  trimming  progresses.  At 
the  starting-point,  the  tissue  to  be  removed  is  caught  up  by  a  small 
tenaculum,  and  cut  away,  by  either  the  scissors  or  the  knife,  in  as 
continuous  a  strip  as  possible.  I  frequently  remove  the  whole  surface 
in  a  long  and  single  strip,  by  which  I  am  assured  that  no  portion  has 
been  left  undenuded. 

The  Silver  Suture^  and  Mode  of  Introduction. — Various  substances 
have  been  used  for  sutures  in  the  different  operations  about  the  female 
organs  of  generation.  Silver  wire  made  from  virgin  silver  annealed 
is  far  superior  to  any  other  metallic  suture;  but  the  article  gene- 
rally sold  is  made  from  coin  silver,  and  is  not  as  servicable  as  the  best 
quality  of  iron  wire.  The  expert  who  brings  the  surfaces  propei'ly 
together  will  frequently  obtain  good  results,  irrespective  of  the  material 
used;  but  the  silver  suture  has  come  into  more  general  use  than  any 
other.  By  the  operator  who  understands  its  application,  no  valid 
objection  will  be  advanced  against  it,  since  experience  has  demon- 
strated its   superiority.      The   metallic  suture  had  been  previously 


48 


SURGICAL    IXSTRUMEXT3    AND    APPLIAXCES, 


Fig.  31. 


employed,  but  to  Dr.  Sims  is  due  the  sole  credit  of  establishing  its 
use.  Since  June  2-1, 1856,  Dr.  Sims^  has  used  the  interrupted  suture 
in  all  operations,  having  found  that  it  simplified  the  performance  and 
fulfilled  every  indication.  When  I  was  his  assistant  in  the  Women's 
Hospital  I  witnessed  the  results  demonstrated  by  him,  and  since  that 
time  my  experience  has  fully  confirmed  his  views. 

The  wire  may  be  attached  directly  to  the  eye  of  the  needle,  and 
thus  introduced ;  but  it  is  liable  to  kink.  The  best  plan  is  to  pass 
first  a  silk,  or  thread,  loop,  and  use  it  for  drawing  in  the  wire.  The 
eye  of  the  needle  must  be  sufficiently  large  to  admit  both  ends  of  the 
thread  to  form  the  loop,  and  this  should  be  about  six  inches  long. 
The  needle  must  be  large  enough  to  admit  of  its  ready  passage  with 
a  half  knot,  which  is  to  be  made  close  to  the  eye  to  prevent  the  thread 
from  slipping  out. 

With  a  tenaculum  to  steady  the  parts,  the  point  at  which  the  needle 
is  to  be  introduced  is  caught  up,  and  the  needle  is  inserted  just  behind 
it.  The  needle  is  then  advanced  by  the  forceps 
into  the  tissues,  and  as  soon  as  the  point  appears 
its  progress  is  aided  by  making  counter-pressure 
with  the  blunt  hook  passed  over  the  point,  as  shown 
in  Fig.  31.  When  it  is  through  as  far  as  the  head 
of  the  forceps  will  admit  of,  the  exposed  portion  of 
the  needle  is  to  be  seized  and  drawn  entirely  out, 
counter-pressure  being  continued  with  the  blunt 
hook. 

As  each  loop  has  been  introduced,  it  is  better  to 
follow  at  once  with  the  wire,  for  the  silk  soon 
becomes  weakened  after  being  saturated  with  blood 
or  urine.  The  wire  is  to  be  attached  to  the  thread- 
loop,  as  already  described,  and  flattened  with  the 
wire-forceps,  so  as  to  offer  no  resistance  in  its  pas- 
When  a  number  of  sutures  ai-e  required,  to  save  time  and  some 
confusion  afterwards,  shorten  each  suture  by  drawing  it  well  through, 
make  a  small  loop  in  the  short  end,  and  pass  the  long  one  through  it, 
to  be  held  by  the  assistant  behind  the  speculum  until  needed  for 
twisting. 

The  use  of  the  "  feeder"  has  already  been  referred  to,  and  Fig.  32 
shows  its  application.      The  suture  A  is  held  in  one  hand,  and,  by 


sage. 


»  See  Silver  Sutures  in  Surgery  (p,  21),  by  J.  Marion  Sims,  M.D.,  New  York, 
1858. 


SILVER    SUTURES, 


49 


Fig.  33. 


means  of  the  instrument  in  the  other,  it  is  made  to  pass  tlirough  the 
tissues  in  the  direction  B.     Frequently,  the  suture  would  cut  through 
without  the  use  of  this  instru- 
ment,  if   the    traction   were  Fig.  32. 
made  at  a  sharp  angle  to  the 
line  of  introduction.      Each 
suture  should  be  made  to  in- 
clude   a    liberal    amount    of 
tissue,  and,  as  a   rule,  from 
four  to  five  should  be  intro- 
duced to  the  inch. 

It  was  fonnerly  thought 
necessary  for  the  sutures  to 
be  introduced  with  the  great- 
est care,  so  that  the  points  of 

entrance  and  exit  should  be  equally  distant  from  the  edges  of  the  two 
surfaces  to  be  united.  The  principle  is  correct,  for  it  is  important  to 
avoid  the  approximation  of  a  freshened  surface 
with  an  opposite  portion  which  has  not  been  de- 
nuded, since  no  union  would  take  place,  and 
the  line  would  be  weakened.  But,  in  reality, 
to  introduce  the  sutures  with  any  such  accuracy 
is  almost  impossible,  even  under  constant  prac- 
tice, and  with  the  parts  most  favorably  situ- 
ated. Within  a  reasonable  limit,  this  great  accu- 
racy is  unnecessary  if  the  sutures  are  properly 
"shouldered"  at  the  time  of  securing  them,  so 
that  the  point  of  twisting  shall  be  immediately 
over  the  line  of  union;  in  other  words,  each  end 
of  the  suture  must  be  bent  on  itself  flat  to  the 
vaginal  surface  at  the  point  of  exit,  and  again  at 
a  right  angle  just  over  the  edge  of  the  surface 
to  be  united.  Fig.  33  represents  surfaces  brought 
together  by  two  sutures,  which  have  been  bent  in 
the  manner  described,  and  secured  by  being  twisted  up  to  the  angle 
over  the  line  to  be  united,  w^hile  the  lower  suture  has  been  "  shouldered" 
in  like  manner,  but  has  not  yet  been  twisted.  If  the  suture  be 
carefully  bent  at  a  right  angle  over  the  line,  and  only  twisted  up 
to  this  point,  it  is  evident  that  there  can  be  no  turning  in  of  either 
border.  We  generally  introduce  first  the  suture  most  distant  from 
the  operator,  and  continue  in  this  order,  for  by  doing  so  we  are 
4 


50 


SURGICAL    INSTRUMENTS    AND    APPLIANCES. 


able  to  avoid  all  confusion  as  each  in  turn  is  held  over  the  upper 
side  of  the  speculum  by  the  assistant.  Therefore,  when  we  begin  to 
twist  the  sutures,  it  will  be  generally  most  convenient  to  secure  first  the 
suture  nearest  to  the  vaginal  outlet,  which  will  also  have  been  the  last  one 
introduced.  In  other  words,  having  looped  together  the  ends  of  each 
of  the  wires  as  introduced,  and  placed  them  under  the  hand  of  the 
assistant  holding  the  speculum,  we  twist  the  sutures  in  inverse  order 
from  that  in  which  they  are  passed.  By  following  up,  with  a  tenacu- 
lum or  blunt  hook,  either  strand  of  wire  from  the  edge  of  the  surface 
to  be  united,  we  can  easily  disengage  its  fellow  from  the  others,  since 
they  have  been  looped  together.  We  then  hold  the  long  end  of  the 
wire  in  the  left  hand,  and  shorten  the  loop  by  traction,  to  about  three- 
quarters  of  an  inch  in  length.  With  the  twisting-forceps  the  little 
slip-knot  is  seized  so  as  to  make  sure  that  both  ends  of  the  suture  are 
included  within  its  grasp,  and  the  excess  of  wire  is  cut  off  close  to  the 
instrument.  Sufficient  traction  is  made  on  the  silver  loop,  with  counter- 
pressure  from  the  flat  side  of  the  tenaculum,  to  bring  the  edges  to- 
gether, then  each  strand  is  shouldered  properly,  as  already  described. 
After  introducing  the  loop  within  the  slit  of  the  shield,  bring  the 
forceps  and  the  handle  of  the  former  close  together,  as  shown  in  Fig. 
34,  and  twist  until  the  angle  formed  by  the  crossing 
of  two  strands  of  wire  is  lost,  just  at  the  edge  of  the 
slit  in  the  shield.  If  this  edge  has  been  made  as 
thin  as  possible,  over  which  the  suture  is  to  be  bent 
by  moderate  traction,  as  the  instruments  are  brought 
together,  and  if  the  twisting  is  not  carried  beyond 
a  given  point,  it  is  evident  that  with  ordinary  care 
the  denuded  surfaces  only  will  be  brought  into  ap- 
position. 

Drawing  up  of  the  suture  with  too  great  traction, 
and  continuing  the  twisting  beyond  the  proper  point, 
so  as  to  strangulate  the  parts  included  within  the 
loop,  can  be  the  only  cause  for  a  metallic  suture  ever 
cutting  out,  if  the  parts  are  in  a  healthy  condition, 
and  have  been  properly  freed  from  tension  before 
the  operation. 

As  it  is  very  necessary  that  each  suture  should 
lie  flat  on  the  vaginal  surface,  after  it  has  been  secured,  withdraw  the 
shield,  and,  while  still  grasping  the  suture,  pass  a  tenaculum  (see  Fig. 
35)  beneath  the  twisted  portion,  close  to  the  line  of  union,  in  order  to 


Fig.  34. 


HOT-WATER    VAGINAL    INJECTIONS. 


51 


Fisr.  35. 


lift  it  up  ;  bend  the  wire  down,  by  moderate  traction,  over  the  tenacu- 
lum used  as  a  fulcrum,  withdraw  the  tenaculum,  and  press  the  wire 
down  with  it  near  the  end  of 
the  forceps,  as  the  latter  is  made 
to  bend  the  wire  upward  again  in 
the  opposite  direction.  Cut  the 
wire  just  at  the  angle  thus  made 
and  it  will  be  found  that  the  suture 
will  be  perfectly  flat.  The  angle 
where  the  suture  is  to  be  cut  off, 
should  be  made  about  half  an  inch 
from  the  line  of  union.  Where 
there  is  room  to  admit  of  doing  so, 
it  is  well  to  turn  the  sutures  alter- 
nately to  opposite  sides,  as  a  guide 
afterwards  for  their  removal,  as 
some  of  them  occasionally  become 
imbedded  in  the  tissues. 

The  proper  time  for  removing  the  sutures  is  usually  between  the 
seventh  and  tenth  days,  but  this  will  be  more  specifically  stated  when 
treating  of  the  special  operations.  They  are  removed  by  gently  ele- 
vating each  in  turn  with  the  forceps,  and  clipping  the  nearest  side  of 
the  loop,  so  that,  as  the  suture  is  withdrawn,  it  will  continue  to  bind 
the  parts  until  cleared. 


Hot-iuater  Vaginal  Injections. — It  will  be  shown  hereafter  that  the 
hot-water  vaginal  injections,  of  different  degress  of  temperature,  ac- 
cording to  the  circumstances  of  the  case,  will  prove  an  invaluable  aid 
in  the  treatment  of  all  conditions  of  uterine  disease.  It  is,  therefore, 
of  the  greatest  importance  that  they  should  be  administered  properly. 
When  given  in  the  upright,  or  sitting  position,  the  effect  is  merely  to 
wash  ovit  the  vagina  without  otherwise  exercising  more  than  a  very 
limited  influence.  Experience  has  shown  that  the  full  benefits  of 
these  injections  can  be  obtained  only  by  administering  them  while  the 
patient  is  lying  on  the  back,  and  that  she  cannot  efficiently  give  them 
to  herself.  It  is  also  necessary  that  her  hips  should  be  elevated,  and 
the  quantity  of  water  used  should  not  be  less  than  half  a  gallon  for 
each  injection. 

A  bed-pan  of  proper  shape  and  size  is  indispensable  to  protect  the 
clothing  of  the  patient.  The  one  known  in  the  crockery  shops  as  the 
English  bed-pan,  but  now  somewhat  out  of  use,  answers  the  purpose 


52  SURGICAL    INSTRUMENTS    AND    APPLIANCES. 

very  well.  For  temporary  use,  the  India-rubber  inflated-cusbion  bed- 
pan will  answer,  but  it  is  liable  to  stick  together  from  the  effects  of 
the  hot  water. 

The  shovel-shaped  French  bed-pan,  more  in  general  use  in  the  sick 
room,  does  not  answer  for  this  purpose,  as  it  allows  the  clothing  of  the 
patient  to  become  wet.  When  using  the  regular  bed-pan,  it  is  neces- 
sary to  place  the  patient  so  far  forward  on  it  that  her  weight  will  not  tilt 
it  up.  Or  the  handle,  which  is  hollow,  may  be  turned  to  one  side,  and 
with  a  piece  of  large  India-rubber  tubing  stretched  over  it,  the  water 
be  made  to  pass  off  into  a  receptacle  placed  along  side  of  the  bed. 
For  use  in  my  private  hospital  I  have  this  form  of  bed-pan  made  of 
copper,  and,  instead  of  so  large  a  handle,  a  small  spout  which  can  be 
kept  closed  when  not  needed,  by  screwing  on  a  cap.  When  a  large 
injection  is  needed,  the  cap  can  be  removed,  and  a  small  piece  of 
tubing,  placed  over  the  spout,  will  carry  off  the  water. 

The  injection  can  be  better  given  to  the  patient  after  she  is  un- 
dressed for  the  night  and  in  bed.  She  should  be  placed  near  the  edge 
of  the  bed  with  the  hips  elevated  as  much  as  possible  by  the  bed- 
pan, and  a  small  pillow  under  her  back,  the  lower  limbs  being  flexed. 
Her  body  must  be  covered,  to  protect  her  from  cold,  and  her  position 
made  perfectly  comfortable  ;  whenever  the  bed  is  a  soft  one,  for  the 
purpose  of  keeping  the  hips  elevated,  a  broad  board  should  be  placed 
under  the  pan  to  prevent  it  from  sinking  into  the  bed  from  the  weight 
of  the  patient.  The  vessel  of  hot  water  is  placed  on  a  chair  by 
the  bedside,  and  the  nurse  passes  the  nozzle  of  the  syringe  into 
the  vagina,  over  the  perineum,  directing  it  along  the  recto-vaginal 
wall  until  it  has  reached  the  posterior  cul-de-sac.  The  water  must  be 
thrown  in,  at  first,  very  carefully,  until  the  vagina  has  become  dis- 
tended. If  the  nozzle  is  not  properly  introduced,  a  stream  of  water 
may  be  throAvn  directly  into  the  uterine  canal.  The  forcible  entrance 
of  any  fluid  into  the  undilated  uterus  causes  intense  pain,  frequently 
alarming  symptoms  of  nervous  prostration  or  collapse,  and  sometimes 
it  is  the  cause  of  an  attack  of  cellulitis.  At  the  completion  of  the 
injection,  the  vagina  can  be  emptied  by  depressing  the  perineum  for 
a  few  seconds,  with  the  finger  on 'the  nozzle  of  the  syringe  before  with- 
draAving  it,  and,  as  the  bed-pan  is  removed,  a  napkin  should  be  placed 
against  the  vaginal  outlet  to  absorb  an}^  water  which  may  have  been 
retained.    . 

When,  from  the  force  of  circumstances,  the  injections  cannot  be 
thus  administered,  it  is  better  to  use  a  fountain,  or  siphon,  syringe  than 
that  the  patient  should  attempt  to  give  them  to  herself.     This  mode, 


THE    VAGINAL    SYRINGE, 


63 


however,  can  only  be  regarded  as  a  substitute,  for  it  is  never  as  effi- 
cacious. In  any  event  the  same  elevated  position  of  the  hips  is  neces- 
sary. A  steady  stream  is  never  as  serviceable  as  the  interrupted 
current  from  a  Davidson's  syringe.  Hence  it  would  seem  as  if,  in 
addition  to  the  heat  of  the  water,  the  jet  from  the  syringe  acted  as  a 
stimulus  to  excite  the  bloodvessels  to  contraction. 

Dr.  Frank  P.  Foster,  of  this  city,  has  had  constructed  an  arrange- 
ment by  which  the  bed-pan  can  be  dispensed  with,  but  an  assistant  is 
necessaiy  to  administer  the  injection.  A  cup  or  shield  A,  Fig.  3fi,  is 
made  by  depressing  one  half  of  an  India-rubber  bag  into  the  other  half, 


Fig.  36. 


Foster's  vaginal  syringe. 

and  screwing  the  two  together  at  D.  This  point  is  pierced  by  the  pipe 
of  a  Davidson's  syringe,  and  fixed  in  position  by  a  brass  cap.  On 
compressing  the  bulb  F,  the  water  is  forced  directly  through  the  vaginal 
portion,  or  nozzle,  of  the  syringe,  which  is  pierced  with  a  number  of 
small  holes.  Now,  as  the  soft  India-rubber  cup  A  is  held  over  the 
labia,  the  only  escape  for  the  water  is  by  the  tube  C  into  a  receptacle. 
The  nozzle  B  is  attached  by  a  short  piece  of  tubing  to  the  brass  cap 
D,  so  that  it  is  movable.  It  is  necessary  that  the  patient's  hips  should 
be  elevated  so  that  the  vagina  may  be  kept  fully  dilated,  and  only  the 
surplus  water  flow  ofi'  by  the  tube  C.  This  arrangement  is  far  supe- 
rior to  the  fountain  syringe,  and,  if  the  patient  can  be  kept  dry  under 
all  circumstances,  it  will  prove  a  most  valuable  contribution.  The 
doctor  has  demonstrated  for  me  the  working  of  the  instrument  on 
several  cases,  none  of  which  were  selected,  and  there  was  no  leakage 
of  any  consequence  in  any,  but  I  think  the  shield  might  occasionally 
get  displaced,  as  the  nurse  has  to  hold  it  firmly  against  the  labia 


54  SURGICAL    INSTRUMENTS    AND    APPLIANCES. 

while,  at  the  same  time,  she  is  giving  the  injection.  This  difficulty, 
however,  can  he  easily  overcome  by  attaching  two  straps  from  the 
cap  D,  one  to  be  passed  under  the  patient's  back,  where  it  will  be 
secured  by  her  weight,  and  the  other  over  the  pubes,  to  be  held  by 
her  hand,  so  that,  after  the  shield  has  been  once  adjusted,  it  can  be 
kept  firmly  in  place. 

Vaginal  Tamijon. — The  efficiency  of  a  vaginal  tampon  consists  in 
controlling  uterine  hemorrhage,  and,  at  the  same  time,  making  uni- 
form pressure  on  the  vaginal  walls,  by  which  much  of  the  blood  sup- 
plied to  the  uterus  is  cut  off.  To  put  in  a  tampon  properly  is  an 
accomplishment  possessed  by  very  few.  The  plan  followed,  of  pass- 
ing in  with  the  finger  a  few  pieces  of  oiled  rag,  a  little  loose  cotton, 
or  one  portion  after  another  of  a  roller  bandage,  is  worse  than  useless. 
It  is  impossible  to  tampon  the  vagina  effectually  without  the  aid  of 
Sims' s  speculum,  for  the  mere  stoppage  of  the  escape  of  blood  from 
the  vaginal  outlet  is  not  sufficient  when  the  accumulation  continues 
unsuspected  in  the  upper  part  of  the  vagina.  When  the  uterine 
hemorrhage  is  free,  we  must  prevent  its  escape  from  the  os,  as  far  as 
possible,  for  which  it  may  even  be  necessary  to  tampon  the  lower 
portion  of  the  uterine  canal.  There  is  no  danger  of  the  uterus 
enlarging  from  concealed  hemorrhage,  as  after  labor,  nor  do  I  think 
the  probabilities  are  any  greater  of  the  escape  of  blood  through  the 
Fallopian  tubes  into  the  peritoneal  cavity.  The  formation  of  a  clot 
within  the  canal  will  excite  the  uterus  to  contraction,  by  which  it  will 
be  forced  out  into  the  vagina.  This  is  just  the  condition  we  wish  to 
bring  about,  for  as  the  uterus  contracts,  its  vessels  are  compressed, 
and,  consequently,  the  flow  of  blood  will  be  checked. 

The  best  material  for  tamponing  the  vagina  is  damp  cotton.  Soak 
a  quantity  of  it  in  water,  and  squeeze  the  mass  nearly  dry.  Then  wet 
it  again  thoroughly  in  a  saturated  solution  of  alum,  and  again  squeeze 
out  the  fluid.  But  before  the  cotton  has  become  too  dry,  it  must  be 
separated  into  portions,  so  that  when  the  edges  are  turned  over,  and 
the  mass  compressed  between  the  hands,  each  portion,  or  pledget,  will 
be  about  two  inches  square,  and  half  an  inch  thick.  If  the  pieces 
are  then  placed  one  on  another,  they  will  not  become  too  dry  before 
they  can  be  used. 

Before-  introducing  the  tampon,  the  bladder  must  be  emptied,  and 
the  patient  placed  in  the  proper  position  on  her  left  side,  and  the 
speculum  introduced,  all  the  blood  and  clots  must  be  first  removed 
from  the  vagina,  and  the  Avhole  passage  mopped  out  with  a  piece  of 


THE    VAGINAL    TAMPON.  .55 

damp  sponge  held  by  a  pair  of  lonj^  dressing  forceps,  or  in  a  sponge 
holder.  When  the  bleeding  is  profuse,  it  is  often  necessary  to  make 
an  application  of  iodine  to  the  uterine  cavity,  to  excite  contraction. 
After  a  portion  of  cotton  has  been  properly  twisted  on  the  applicator, 
and  the  instrument  has  been  bent  to  the  curve  of  the  uterine  canal,  it 
is  to  be  dipped  into  the  iodine  and  passed  to  the  fundus.  I  frequently 
leave  the  cotton  in  the  canal,  to  get  the  fuller  effect  from  the  iodine, 
and  it  can  be  done  with  safety  if  a  portion  of  it  is  left  projecting  from 
the  OS.  If  we  wish  to  leave  the  cotton  behind,  it  is  only  necessary  to 
loosen  it  from  the  applicator,  by  giving  the  instrument  several  turns 
between  the  fingers  in  the  opposite  direction  to  that  in  which  it  was 
put  on.  The  applicator  will  carry  the  cotton  to  the  fundus,  and  it  is 
then  only  necessary  to  apply  the  nail  of  the  index  finger  against  one 
side  of  the  instrument,  as  it  is  withdrawn,  to  cause  the  cotton  to  slip 
off  and  lie  at  full  length  in  the  canal. 

We  should  begin  the  packing  of  the  vagina  by  placing  over  the 
cervix  a  pledget  of  cotton,  dampened  afresh  with  the  solution  of  alum. 
Then  roll  up  a  mass  and  place  it  in  the  posterior  cul-de-sac,  close  to 
the  cervix,  with  a  similar  one  on  each  side  and  in  front,  and  a  flat 
portion  over  all.  Begin  then  to  place  the  pledgets  around  the  cervix 
in  a  circle,  and  fill  in  the  centre.  When  the  mass  has  been  packed  in, 
and  reaches  the  vaginal  walls,  take  a  stout  whalebone  stick  to  press 
back  the  cotton  from  the  sides,  and,  as  room  is  thus  gained,  a  portion 
of  cotton  must  be  slipped  into  place  with  a  pair  of  dressing  forceps. 
Continue  thus  to  go  around  and  around  the  mass,  pressing  it  back 
from  the  circumference  towards  the  centre,  and  packing  in  the  pledgets 
wherever  space  is  gained.  When  the  vagina  has  become  well  filled 
by  the  tampon,  this  is  to  be  pressed  firmly  back  with  the  stick  from  the 
anterior  wall  of  the  vagina  towards  the  hollow  of  the  sacrum,  and  the 
speculum  slipped  in  front  of  the  mass.  As  the  speculum  is  then  drawn 
back  by  the  assistant,  the  space  left  will  extend  nearly  up  to  the 
uterus.  This  is  to  be  filled  in  in  the  same  manner,  and  the  speculum 
withdrawn  jjari  passu,  until  the  whole  canal  shall  have  been  firmly 
packed.  No  force  should  be  used,  but,  by  going  around  and  around 
the  mass,  and  firmly  packing  in,  with  the  forceps,  one  small  portion 
after  another,  we  can  gradually  dilate  the  vagina,  if  necessary,  until 
the  whole  basin  of  the  pelvis  is  filled  by  the  tampon. 

It  will  be  necessary  under  all  circumstances  to  confine  the  patient 
to  bed,  and  to  give  an  anodyne  if  the  tampon  has  been  a  large  one  ; 
and  the  bladder  will  have  to  be  emptied  by  means  of  a  flexible  male 
catheter.     It  is  best,  as  a  rule,  to  administer  the  anodyne  by  injection 


56  SURGICAL    INSTRUMENTS    AND    APPLIANCES. 

into  the  rectum,  the  preparation  I  generally  use  being  the  acetated 
tincture  of  opium.  Or,  if  more  convenient,  a  suppository  of  mor- 
phine and  belladonna  answers  as  well,  but  it  must  be  passed  high  up 
into  the  rectum  before  the  tampon  is  introduced.  The  most  distress- 
ing symptom  from  a  large  tampon  is  due  to  pressure  on  the  neck  of 
the  bladder.  Should  this  irritation  continue  without  relief  from  the 
anodyne,  the  position  of  the  patient  may  be  shifted  across  the  bed, 
with  her  hips  near  the  edge,  and  her  limbs  flexed,  for  the  purpose  of 
carefully  removing  a  portion  of  the  cotton  lying  near  the  neck  of  the 
bladder.  With  the  index  finger  as  a  guide  this  may  be  done  by  for- 
ceps, or  better  by  twisting  the  notched  whale-bone  swab-stick  into  each 
piece,  which  will  remove  the  cotton,  as  a  charge  from  a  fowling  piece 
is  removed  by  the  gun-screw.  After  pressure  has  been  exerted  for  a 
few  hours,  the  vessels  will  have  had  time  to  contract,  so  that,  as  a 
rule,  a  suiEcient  quantity  of  the  cotton,  to  give  relief,  may  then  be 
removed  with  safety  if  the  patient  continues  to  keep  the  horizontal 
position.  Notwithstanding  the  astringent  and  disinfectant  properties 
of  the  alum,  it  will  be  necessary  after  twenty-four  or  thirty-six  hours, 
to  remove  the  tampon,  since  by  that  time  it  Avill  have  become  offensive 
from  being  saturated  with  blood  and  the  secretions.  After  its  removal 
a  large  injection  of  hot  water  containing  a  little  impure  carbolic  acid 
should  be  administered,  to  wash  out  the  vagina  thoroughly,  after 
which  the  tampon  may  be  replaced  if  necessary.  As  the  flow  will,  in 
all  probability,  have  been  greatly  lessened  by  the  pressure  of  the  first 
tampon,  the  second  one  will  not  need  to  be  so  large.  Before  replac- 
ing the  tampon  it  is  well  to  encircle  the  cervix  with  several  pledgets 
of  cotton  saturated  with  glycerine.  This  fluid  is  not  only  a  good  dis- 
infectant, but  it  will  render  the  condition  of  the  patient  more  comforta- 
ble by  removing  the  heat  and  dryness  of  the  vagina  which  habitually 
follow  the  use  of  the  alum  and  tampon. 


DIAGNOSIS.  57 


CHAPTER    IV. 

FORM  FOR  A  RECORD  OF  CASES  ;    MODE  OF  EXAMINATION  ;    CHIEF 
POINTS  FOR  FORMING  A  DIAGNOSIS. 

Blank  form  for  records — Neatness  in  person  and  instrument — Examination  table — 
Digital  examination:  its  value;  mode  of  making  it;  points  to  be  noted — Con- 
joined examination — Physical  signs  of  a  retroverted  uterus  ;  of  a  flexed  uterus ; 
of  a  uterine  fibroid — Enlarged  uterus  :  dilFerentiated  from  pregnancy,  and  from 
other  bodies,  growths,  tumors,  hemorrhagic  collections,  etc. — Condition  of  vagina, 
urethra,  bladder,  cervix  uteri,  perineum,  rectum  —  Dilating  the  urethra,  a 
reprehensible  practice. 

Mode  of  using  the  speculum — Points  to  be  noted — Use  of  probe — Latent  cellulitis. 

It  is  necessary  that  some  record  should  be  kept  of  every  case,  for 
future  reference.  While  the  fullest  details  on  all  points  of  practical 
value  should  be  recorded,  it  is  essential  that  this  be  done  in  a  con- 
densed form.  When  accustomed  to  keeping  such  records,  we  will  be 
able,  after  a  few  questions,  to  form  a  sufficiently  accurate  opinion,  as 
to  the  difficulty  from  which  the  patient  is  suffering,  to  lead  us  to  seek 
information  from  her  on  the  essential  points  only,  so  as  to  economize 
both  time  and  labor. 

When  consulted  for  the  first  time,  it  is  necessary  to  hear  something 
of  the  patient's  statement  given  by  her  own  prompting,  as  she  will, 
doubtless,  have  settled  beforehand  in  her  own  mind  the  all-important 
featui'es.  Notwithstanding  that  they  are  likely  to  have  but  little 
bearing  upon  the  case,  the  physician  must  patiently  listen  long  enough 
for  her  to  feel  that  it  is  being  thoroughly  investigated,  for  this  will 
inspire  confidence  at  the  beginning.  If  she  is  nei-vous  she  should  be 
encouraged  to  give  her  own  statement,  in  order  to  give  her  time  to 
collect  herself,  and  fit  her  to  answer  intelligently  afterwards,  the 
necessary  questions  to  be  asked.  But  I  make  it  a  rule,  after  having 
fully  heard  the  patient,  and  once  having  begun  to  record  the  history 
of  the  case,  that  she  shall  only  answer  my  questions. 

The  following  outline  I  generally  use  for  my  record  of  cases,  and 
by  filling  in  Avith  the  special  points  of  each,  a  full  history  can  be  se- 
cured. It  will  be  necessary  to  leave  ample  space  in  the  case  book 
for  "First  symptoms  of  disease,"  "Present  condition,"  for  what 
"Physical  examination"  discloses,  and  for  the  "After  history  and 


58  FORM    OF    RECORDS. 

treatment."  T  give  here  the  history  of  an  imaginary  case,  one  fre- 
quently met  with  in  practice,  and  the  portion  printed  in  italics  showing 
the  methods  of  filling  in. 

DATE  OF  FIEST  COXSULTATIOX.       Jan.   ISt,   lSj6.  BECOMMEITDED  BT 

EEsroESCE.     New  York.  Dr.  John  Smith, 

OE  husbaxd's  place  of  business.      Wall  St.  New  York. 

SAME,  J..  jB.  age,  jo.  si::cl5  3XAERIED.  AGE  OF  FIEST  5rEXSTErATio>',  yburfeen. 
EEGrxAE  after  two  months.  Slight  3^  paix,  ix  the  begixxixg  of,  ==SHfS-,  i?55S, 
THE  FLOW,  lasting  /'oiir  days.  gexeeal  health  always  good,  jiaeeied  ten  teaes. 
etmbee  of  chilleen,  one.  ncmbee  of  miscaeeiages,  one.  at  three  months,  last 
peegxanct,  viiscarriage,  eight  teaes  since,  chaeacter  of  last  laboe,  rATUiiAii, 
g£":c~-s,  BAPiD,  iz:ZTiiz"z:::z:^z.  in  laboejhoues.  iZac?  difficcltt  afteewaeds  on 
standing  from  hearing  do^  n,  with  frequent  desire  to  empty  the  bladder.  Did  not  recover 
her  strength.  Unable  to  nurse  her  child.  Received  some  local  treatment,  and  improved 
previous  to  the  miscarriage,  has  sot  been  well  since  birth  of  child,  worse  since  mis- 
carriage, began  to  suffee  afteewaeds  feom  constant  backache,  leucorrhoea,  frequent 
show,  pain  down  the  limbs,  irritability  of  the  bladder  increased,  unable  to  stand  or  walk; 
constipation  of  the  bowels. 

PEESENT  condition.  Has  become  exceedingly  nervous ;  neuralgia  of  the  face;  leucor- 
rhcea  throughout  the  month,  but  more  profuse  after  the  period;  menstruation  somewhat 
irregular  as  to  time,  always  a  day  or  two  too  soon,  lasting  now  six  days,  but  the  quantity 
is  rather  less  than  formerly ;  suffers  now  from  painful  menstruation,  generally  towards  the 
end  of  the  flow ;  has  become  more  constipated,  and  suffers  great  pain  after  each  movement 
of  the  bowels;  irritability  of  the  bladder  has  continued,  and  cannot  walk  or  stand  without 
increasing  the  pain  in  the  back  and  down  the  limbs ;  can  seldom  sleep  without  an  anodyne ; 
frequent  headaches ;  feels  sometimes  as  if  she  woidd  become  insane;  suffers  from  strange 
sounds  and  trouble  in  the  head,  as  if  from  the  dripping  of  water;  has  frequent  attacks  of 
palpitation  of  the  heart;  loss  of  appetite,  etc.;  dyspepsia;  suffers  fj-om  cold  feet. 

PHYSICAL  EXAMINATION  DISCLOSES  laceration  of  the  perineum,  down  to  the  sphincter; 
prolapse  of  the  posterior  wall  of  the  vagina ;  uterus  retroverted  and  enlarged;  cervix 
lacerated  on  both  sides  to  the  vaginal  junction,  and  flaps  rolled  out,  covered  with  an  exten- 
sive erosion ;  profuse  cei-vical  leucorrhcea ;  depth  of  the  uterus  three  inches  and  a  half. 

TREATMENT  AND  RESULT. 


If  we  analyze  the  history  of  the  above  case,  it  will  be  seen  that  the 
patient  was  in  good  health  until  her  labor.  The  first  symptoms  of 
disease,  as  stated,  are  so  characteristic  that  there  would  be  little  doubt 
as  to  what  would  be  found,  even  before  a  digital  examination  had  been 
made.     Her  labor  was  unusually  rapid,  and  attended  with  laceration 


ANALYSIS    OF    RECORDS.  59 

of  the  perineum  and  neck  of  the  uterus.  As  soon  as  she  began  to 
stand  on  her  feet,  prolapse  of  the  posterior  wall  of  the  vagina  com- 
menced. The  laceration  of  the  cervix  would  retard  the  return  of  the 
uterus  to  its  natural  size,  after  the  birth  of  her  child,  and  consecpicntly, 
from  its  increased  weight,  the  organ  would  lie  near  the  floor  of  the  pelvis. 
Gradually,  as  the  rectocele  increased,  the  neck  of  the  uterus  would 
settle  still  further  forward  towards  the  vaginal  outlet,  in  the  direction 
offering  the  least  resistance.  This  would  necessarily  throw  the  fundus 
of  the  womb  backwards,  and  it  would  become  retroverted  just  in  pro- 
portion as  it  advanced  toAvards  the  mouth  of  the  vagina.  As  the  uterus 
was  crowded  downward  the  two  flaps  in  the  lacerated  cervix  would  be 
forced  apart  more  and  more.  This  would  act  as  a  source  of  irritation 
which  would  rapidly  increase  the  size  of  the  uterus,  cover  the  flaps  with 
an  erosion,  and  cause  a  profuse  leucorrhoea,  Avith  backache.  With  the 
increased  weight  of  the  uterus,  pressure  would  be  made  on  the  nerves, 
causing  pain  in  the  limbs,  and,  from  pressure  and  dragging  on  the 
anterior  wall  of  the  vagina,  there  would  be  irritation  of  the  bladder. 
It  may  be  that  she  had  received  some  local  treatment,  and  improved. 
It  is  not  likely,  however,  that  the  laceration  in  the  cervix  Avas  detected, 
nor  the  displacement  corrected.  The  erosion  chiefly  caused  by  the 
secretions  running  over  the  parts,  which  had  increased  in  quantity, 
from  the  effort  of  nature  to  relieve  the  congested  condition  of  the 
uterus,  was  doubtless  supposed  to  be  ulceration,  and  held  to  be  the 
chief  difficulty.  No  doubt,  the  nitrate  of  silver  Avas  applied  until  the 
surface  of  the  supposed  ulcer  become  cicatrized.  A  temporary  im- 
proA'-ement  took  place  in  her  general  health,  and,  before  a  relapse 
could  occur,  she  became  pregnant.  In  consequence  of  the  displace- 
ment of  the  uterus  backwards,  and  the  limited  space  to  Avhich  it  was 
confined  in  the  holloAV  of  the  sacrum,  the  organ  could  not  increase  in 
size  after  a  certain  time.  The  larger  it  became,  the  more  marked 
Avas  the  retroversion  and  the  general  disturbance,  until,  at  length,  as 
a  consequence,  miscarriage  took  place.  This  accident  increased  her 
dijfficulty,  by  leaving  the  uterus  larger  than  it  was  before,  so  that  all 
her  old  symptoms  returned  Avith  greater  force.  From  the  increased 
retroversion,  causing  continued  pressure  on  the  rectum,  habitual  con- 
stipation was  induced,  folloAved  by  a  fissure  or  crack  in  the  anus, 
which  necessarily  added  to  the  difficulty  by  reflex  irritation.  With 
this  condition  of  the  uterus,  sterility  and  irregularities  in  menstruation 
now  followed  as  a  natural  consequence.  The  leucorrhoea  also  kept 
up  a  continued  drain,  from  Avhich,  and  from  the  Avant  of  sunlight,  she 
gradually  began  to  suffer  from  the  effects  of  anaemia,  a  condition  in 


60  MODE    OF    EXAMINATION. 

which  the  blood  is  so  wanting  in  proper  elements  as  no  longer  to  act 
as  a  healthy  stimulus  to  the  nerve  centres.  This  will  fully  account 
for  her  "trouble  in  the  head,"  the  irregular  action  of  the  heart,  and 
for  her  nervousness,  neuralgia,  etc. 

I  have  thus,  in  as  brief  a  manner  as  possible,  pointed  out  the  prac- 
tical bearing  of  the  main  features  of  this  individual  case.  Hereafter 
we  shall  find  different  local  causes  producing  the  same  general  dis- 
turbance, so  that  many  features  of  this  case  Avill  be  found,  in  some 
degree,  common  to  every  one  passing  under  observation. 

Mode  of  Examination  and  Chief  Points  for  forming  a 
Diagnosis. 

A  patient  once  informed  me  that  she  had  refused  to  submit  to  an 
examination  because  she  noticed  that  the  jDhysician  she  consulted  did 
not  keep  his  finger-nails  clean.  This  circumstance  convinced  her  that 
if  he  Avas  so  negligent  of  his  own  person,  he  would  be  quite  as  likely 
to  neglect  the  details  of  her  case.  Althou2:h  her  deduction  did  not 
necessarily  follow,  for  her  own  protection  it  Avas  well  that  she  avoided 
the  risk  of  an  examination.  A  physician  should  always  be  scrupu- 
lously neat  in  his  person,  but  it  is  particularly  essential  that  he  should, 
at  least,  keep  his  nails  short  and  clean.  When  examining  a  number 
of  cases,  if  negligent,  he  will  frequently  cause  vaginitis,  by  transmit- 
ting secretions  under  his  nail,  from  one  patient  to  another.  He  should 
always  wash  his  hands  thoroughly  before  and  after  each  examination, 
always  using  the  nail  brush  after  examining  a  patient  suffering  from 
a  profuse  vaginal  discharge.  Not  only  for  the  protection  of  the  patient 
is  the  precaution  necessary,  but  his  sense  of  touch  will  be  more  acute 
just  after  washing  his  hands.  It  is  equally  necessary  that  every 
instrument  used  in  an  examination  should  be  thoroughly  washed,  and 
where  the  secretions  have  been  of  a  suspicious  character,  a  little 
carbolic  acid,  or  some  other  disinfectant,  must  be  added  to  the  water. 
I  have  found  an  ointment  of  boracic  acid,  in  proportion  of  one  part  to 
six,  very  serviceable  for  common  use,  and  keep  it  on  my  stand  to 
lubricate  the  speculum  and  my- finger  when  making  vaginal  examina- 
tions. 

A  table,  four  feet  long,  thirty  inches  in  hciglit,  without  the  castors, 
and  twenty -four  inches  wide,  has  been  adopted  for  all  operations  and 
examinations  in  my  private  hospital.  For  ray  office  practice,  I  have 
an  invalid  chair,  made  of  the  i)roper  height  and  wide  enough  for  the 
purpose.     The  patient  takes  a  seat,  and,  when  told  to  lean  back  by 


THE    DIGITAL    EXAMINATION.  61 

the  nui'se,  is  placed  in  the  horizontal  position  by  the  upper  portion  of 
the  chair  turning  down.  Such  a  table  as  I  have  described,  covered 
with  several  folds  of  a  blanket  and  a  sheet,  with  a  small  pillow,  answers 
as  well  as,  if  not  better,  than  an  expensive  chair  made  for  the  purpose. 
The  only  objection  to  the  table  is  its  formidable  appearance,  which, 
to  a  new  patient,  is  perhaps  suggestive  of  a  surgical  operation. 

When  the  sense  of  touch  has  been  cultivated,  it  ^delds  more  reliable 
information  for  forming  a  diagnosis  than  can  be  gained  by  the  eye 
alone,  even  when  used  under  equally  favorable  circumstances.  There- 
fore the  digital  examination  should  be  thoroughly  and  systematically 
made.  It  is  all-essential  to  possess  a  knowledge  of  departures  from 
a  healthy  standard,  and,  to  detect  slight  changes,  it  is  equally  impor- 
tant to  realize  the  fact  that,  the  lighter  the  touch,  the  more  thorough 
will  be  the  appreciation  of  the  sense.  It  is  indeed  remarkable  what 
a  diiference  in  this  respect  exists  between  individuals.  One  will 
undertake  the  examination  with  as  much  vigor  as  he  would  use  were 
he  boring  a  hole  into  a  pump-log,  and  is  sensible  to  little  more  than 
the  cervix,  which  feels  like  an  obstruction  in  his  way.  He  will  gain 
no  information  of  importance,  and  will  inflict  unnecessary  pain  on  the 
patient.  Another,  in  less  time,  will  pass  his  finger  lightly  over  every 
portion  of  the  vagina,  and  quickly  gain  information  enough  to  enable 
him  to  fully  understand  the  case  without  having  caused  any  pain. 
The  manner  in  which  I  have  sometimes  seen  this  examination  made, 
even  by  men  of  experience,  could  only  be  described  as  brutal,  in  con- 
sequence of  the  unnecessary  amount  of  suffering  inflicted,  evincing  a 
"want  of  tact  sufficient  to  debar  them  from  the  practice  of  any  other 
branch  of  the  profession. 

A  digital  examination  can  be  most  thoroughly  made  by  placing  the 
patient  on  the  back,  her  limbs  drawn  up,  with  her  hips  near  the  edge 
of  the  table  within  easy  reach  of  the  operator.  She  must  be  covered 
by  a  sheet,  her  knees  separated  fully,  and  her  feet  placed  within  six 
inches  of  each  other.  The  index  finger  of  the  left  hand  is  the  best 
fitted  for  a  vaginal  examination,  since  its  sense  of  touch  is  the  more 
delicate,  and  the  right  hand  is  left  free  for  palpation  through  the 
abdominal  wall.  After  the  hands  have  been  well  washed,  and  the 
index  finger  greased,  the  left  hand  is  to  be  passed  under  the  sheet 
along  the  surface  of  the  table  until  reaching  the  sulcus  between  the 
buttocks.  Then  the  index  finger  is  slid  along  the  perineum  and  over 
the  fourchette  into  the  vagina.  When  the  finger  has  passed  a  short 
distance  w^ithin  the  vagina,  the  perineum  should  be  gently  but  firmly 
depressed  for  the  admission  of  air,  which  will  open  up  the  passage 


62  MODE    OF    EXAMINATION. 

and  give  sufficient  space  for  the  examination.  After  this  the  hand  is 
to  be  rotated,  with  its  palm  uppermost,  so  that  the  curve  of  the  finger 
may  conform  to  that  of  the  vagina  ;  the  other  fingers  and  thumb  being 
clearly  flexed,  so  as  not  to  touch  the  neighborhood  of  the  clitoris.  As 
the  finger  is  advanced  in  the  passage,  the  perineum  must  be  pressed 
backward,  until  the  cervix  has  been  reached. 

"VVe  must  first  note  the  position  of  the  neck  in  the  vagina,  its  size, 
shape,  density,  whether  there  be  an  erosion,  and  the  size  of  the  os. 
The  position  and  size  of  the  cervix  Avill  give  some  indication  of  the 
condition  of  the  uterine  body.  All  of  these  points  are  to  be  studied 
in  their  relation  to  sterility  :  and  the  shape  of  the  neck  if  flexed,  and 
any  narrowing  of  the  os  will  be  of  special  interest,  as  causes  of  pain- 
ful menstruation.  There  will  perhaps  be  symptoms  elicited  in  the 
history  of  the  case  indicative  of  cancer,  and  if  this  be  present,  it  will 
be  recognized  by  some  characteristic  growth  or  ulceration.  But  the 
ordinary  erosion  found  on  the  neck  possesses  little  importance  beyond 
being  an  indication  of  some  obstruction  to  the  circulation.  Unhealed 
surfaces  may  also  be  due  to  lacerations  of  the  cervix — an  injury  oc- 
curring during  childbirth,  and  these  maintain  the  enlargement  of  the 
uterus,  and  keep  up  a  profuse  leucorrhoea.  This  is  a  condition  fre- 
quently overlooked,  yet  it  is  one  of  the  most  important  as  a  cause  of 
disease,  and  its  existence  can  often  be  detected  by  a  digital  examina- 
tion alone. 

We  are  now  to  place  the  right  hand  over  the  abdomen  just  above 
the  pubes,  and,  by  conjoined  manipulation,  with  the  finger  of  the 
other  hand  in  the  vagina,  we  are  to  judge  of  the  size  and  location  of 
the  uterus.  As  shown  in  Fig.  37,  the  right  hand  is  just  about  making 
the  necessary  pressure  on  the  abdomen  to  bring  the  uterus  within 
reach  of  the  two  hands,  from  which  a  very  accurate  idea  can  be 
formed  of  its  size.  By  this  means  we  are  able  to  appreciate  when 
the  uterus  is  in  position  or  when  displaced  forward,  or  to  either 
side  ;  but  when  turned  backward,  the  finger  in  the  vagina  or  rectum 
only  can  recognize  the  exact  condition.  For  judging  of  the  extent  of 
growths  on  the  outer  surface  of  the  uterus,  and  the  relation  of  the 
organ  to  tumors  in  the  neighborhood,  this  mode  of  examination  gives 
us  great  facility.  We  are  to  obtain  the  first  clue  to  the  position  of 
the  uterus,  from  the  finger  in  the  vagina  as  it  is  passed  around  the 
cervix.  With  "the  aid  of  the  other  hand  the  impression  received  will 
be  confirmed,  or  it  will  become  evident  that  other  means  will  have  to 
be  resorted  to  for  settling  the  point.  As  the  finger  is  drawn  forAvard 
from  the  cervix,  we  will  be  able  to  feel  through  the  anterior  wall  of 


POINTS    FOR    DIAGNOSIS, 


63 


the  vagina  and  bladder  -whctbcr  the  uterus  lies  in  that  direction.  We 
must  pass  the  finger  to  each  side  of  the  uterus  to  detect  a  lateral  ver- 
sion, should  one  exist,  and  if  a  mass  is  felt  on  either  side  we  must 
investigate  the  condition  carefully  ;  for  when  we  find  the  uterus  or  a 
thickening  in  this  location,  it  is  to  be  supposed,  until  proved  to  the 

Fi-.  37. 


Vaginal  touch  and  bimanual  examination. 

contrary,  that  inflammation  has  previously  existed  between  the  folds 
of  the  broad  ligament,  and  in  addition  there  w^ill  probably  be  found 
a  laceration  of  the  cervix  on  that  side. 

When  the  uterus  is  retroverted,  it  lies  backward,  so  that  Avhat  was 
its  posterior  surface,  when  in  position,  can  now  be  easily  felt  through 
the  posterior  cul-de-sac  of  the  vagina,  as  shown  in  Fig.  38.  We  can- 
not always  be  sure  that  a  mass  felt  in  this  position  is  the  uterus  retro- 
verted, except  in  the  extreme  condition  of  displacement,  as  shown 
above.  Here  the  neck  wall  be  felt  pointing  in  the  opposite  direction 
from  Avhat  it  would  when  in  a  normal  position,  as  will  be  seen  at  a 
glance  by  comparing  this  condition  with  that  shown  in  Fig.  37.  The 
uterus  in  Fig.  38  has  rotated  from  a  natural  position  through  nearly 
a  third  of  the  circle,  and  we  may,  therefore,  have  the  organ  retro- 
verted at  any  angle  between  these  two  points.  We  may  find  the 
uterus  partially  displaced  backwards,  and  dragged  over  by  a  growth 
on  its  posterior  wall,  or  we  may  find  the  parts  thickened  from  a  pre- 
vious inflammation,  so  that  it  will  be  necessary  to  use  the  probe  in 


64 


POINTS    FOR    DIAGNOSIS, 


order  to  ascertain  the  true  condition.  The  body  of  the  uterus  is 
frequently  bent  upon  itself,  forming  a  flexure  which  cannot  always  be 
distinguished,  by  the  finger  in  the  vagina,  from  an  outgrowth  on  the 


Fig.  38. 


<^T 


Ketroverted  uterus. 


surface  of  tlie  organ.  For  instance,  in  Fig.  39,  it  is  shown  that  the 
fino^er  would  easily  detect  the  sulcus  at  A  and  B,  and  with  the  uterus 
lying  forward,  the  condition  would  be  supposed  to  be  one  of  anteflexion 
in  both  instances.  At  B,  flexure  of  the  body  forward  does  exist, 
while  at  k.  is  shown  a  fibroid  growing  out  from  the  front  of  the  uterus, 
with  the  canal  unobstructed,  and  the  organ  nearly  in  position.  By 
conjoined  manipulation  we  might  be  able  to  detect  the  difference 
between  the  two  conditions,  but  there  would,  in  all  probability,  remain 
a  doubt  until  the  direction  of  the  uterine  canal  is  determined  by  means 
of  the  probe.  If  we  reverse  this  condition  we  can  easily  imagine  that 
the  same  difficulty  would  present  itself  in  the  diagnosis  between  a 
retroflexion  and  a  partial  retroversion  due  to  a  fibroid  growing  from 
the  posterior  wall,  which  question  could  only  be  settled  by  the  same 
means.  Bodies  smaller  than  the  uterus  may  sometimes  be  felt  in  the 
pelvis,  with  the  uterus  displaced,  and  it  becomes  of  importance  to 
detect  their  connection  and  nature.    Either  an  enlarged  and  prolapsed 


MOBILITY    OF    THE    UTEllUS, 


65 


ovary,  a  cyst  in  the  broad  ligament,  or  a  pedunculated  fibroid  may 
displace  the  uterus.  An  ovary  enlarged  sufficiently  to  prolapse  "will 
always  be  found  in  Douglas's  cul-de-sac,  generally  under  the  retro- 
verted  uterus,  and  it  is  very  painful  on  pressure.  Its  range  is  neces- 
sai-ily  very  limited,  as  it  is  confined  to  one  side  of  the  median  line, 
and  can  be  moved  only  in  the  direction  from  which  it  prolapsed. 

Fiff.  39. 


Cysts  are  chiefly  found  in  the  ovary  and  broad  ligament ;  they  are 
not  painful  on  pressure,  and  do  not  prolapse  into  the  cul-de-sac,  as 
does  an  enlarged  ovary.  By  passing  the  finger  into  the  rectum  ayo 
are  generally  able  to  detect  their  true  character.  A  pedunculated 
fibroid  is  very  dense,  and  is  not  sensitive  to  the  touch.  "When  the 
pedicle  is  long  enough  to  admit  of  the  usual  freedom  of  motion,  the 
tumor  will  seldom  be  found  twice  in  the  same  position,  and  will,  in 
turn,  displace  the  uterus  backward  or  forward. 

At  an  early  stage  of  the  digital  examination,  it  is  of  great  import- 
ance to  form  an  accurate  opinion  as  to  the  mobility  of  the  uterus,  not 
only  as  to  its  connection  w^ith  a  neighboring  growth,  but  equally  in  the 
absence  of  any  such  body.  If  we  are  able  to  appreciate,  by  means 
of  the  finger,  that  the  uterus  is  not  as  movable  as  it  should  be,  we 
must  proceed  in  the  examination  with  great  care,  under  the  supposi- 
tion that  there  has  been  inflammation  of  the  connective,  or  cellular, 
tissue  about  the  uterus ;  and  while  it  is  necessary  to  ascertain  its 
character  and  extent,  the  examination  must  not  be  conducted  roughly, 
as  it  might  result  in  bringing  on  an  acute  attack. 
5 


66  POINTS    FOE    DIAGNOSIS. 

When  the  uterus  is  found  to  be  enlarged,  we  must  make  an  attempt 
to  ascertain  the  cause  of  the  enlargement,  for,  until  this  has  been 
accurately  determined,  we  cannot  institute  the  proper  treatment. 
The  presence  of  a  mass  in  the  pelvis  or  abdomen  may  be  readily 
appreciated  by  the  bimanual  examination,  but  it  may  require  a  syste- 
matic investigation  before  it  can  be  determined  whether  it  consists 
of  an  enlarged  uterus,  an  external  growth  involving  the  organ,  or  of 
one  in  its  proximity.  In  view  of  the  various  possible  conditions,  we 
are  to  conduct  the  examination  somewhat  in  the  following  order,  not 
because  it  implies  any  relation  to  the  frequency  of  occurrence  of  one 
or  the  other,  but  because  it  will  enable  us  to  exclude  with  certainty 
each  successive  condition,  and  so  expedite  our  examination  without 
detriment  to  the  patient : — 

1.  Pregnancy. 

2.  Enlargement  of  the  uterus,  with  cellulitis  or  hsematocele. 

3.  Enlargement  remaining  after  a  miscarriage  or  childbirth. 

4.  Enlargement  of  the  uterus  from  growths  in  its  walls  and  within 
its  cavity. 

5.  Congestive  hypertrophy  of  the  uterus  in  the  unmarried  or  sterile. 

6.  Ovarian  tumors,  extra-uterine  pregnancy,  and  other  growths  in 
proximity  to  the  uterus.  The  previous  history  of  the  case  will  gene- 
rally be  an  important  guide  to  the  condition,  but  cannot  be  relied 
upon  exclusively. 

When  we  have  ascertained  from  the  patient  that  the  menstrual  flow 
has  been  absent  for  several  months,  the  natural  inference  is  that 
pregnancy  exists,  but  the  length  of  time  since  the  disappearance  of 
the  flow  should  bear  some  relation  to  the  size  of  the  uterus  at  the 
time  of  the  examination.  Pregnancy  may  be  suspected,  but  we  have 
no  sure  and  lawful  means  of  proving  its  existence  before  quickening, 
when  the  enlarged  uterus  rises  from  the  pelvis  into  the  abdominal 
cavity.  When  this  has  occurred,  the  motion  of  the  child  may  be  felt, 
and  the  beating  of  the  foetal  heart  detected,  which  must  be  accepted 
as  conclusive  evidence.  The  uterus  will  be  then  found  softer  and 
more  uniform  in  shape  than  when  enlarged  from  a  fibrous  tumor  in  its 
wall.  The  history  of  the  case,  should  a  fibrous  tumor  be  present, 
would  also  show  the  previous  existence  of  hemorrhages  for  a  longer 
period  than  that  during  which  pregnancy  could  have  existed.  It 
would  be,  therefore,  in  the  early  months  of  pregnancy  that  the  chief 
difiiculty  in  making  a  diagnosis  would  be  experienced.  All  the  early 
symptoms  of  pregnancy  may  also  result  from  enlargement  of  the  uterus 
from  other  causes,  and  a  "show"  may  occur,  with  some  regularity, 


CELLULITIS  —  nEMORRIIAQE.  67 

for  several  months  after  pregnancy  has  taken  place,  from  an  erosion 
at  the  neck.  AVe  are,  therefore,  always  to  be  on  the  lookout  for  such 
a  complication,  and  when  in  doubt,  it  is  better  to  wait  a  few  months 
until  the  true  condition  can  be  established  without  risk  of  injury  to 
the  patient.  To  bring  about  an  abortion  by  our  own  carelessness  in 
the  mode  of  examination,  is  quite  as  culpable  as  when  done  with 
criminal  intent.  The  condition  must  be  very  rare  indeed  in  which 
some  evidence  would  not  be  present  to  lead  us  to  suspect  the 
possible  existence  of  pregnancy,  were  we  to  conduct  the  investi- 
gation properly.  I  have  frequently  had  women  consult  me,  giving 
fictitious  statements  of  their  cases,  and  when  I  had  concluded  the 
examination,  merely  a  digital  one,  they  have  expressed  their  sur- 
prise that  I  had  not  passed  the  sound.  They  have  candidly  acknowl- 
edged that  they  had  known  of  their  pregnancy,  and  came  to  be 
examined,  thinking,  that  as  I  was  accustomed  to  the  introduction  of 
the  sound,  it  Avould  be  passed  without  injury  to  them,  but  would  be 
the  means  of  producing  an  abortion.  "We  are,  therefore,  to  be  con- 
tinually on  guard,  as  a  matter  of  conscience,  for  our  own  protection, 
and  in  the  interest  of  the  patient,  who  may  not  be  aware  of  her  situa- 
tion ;  for  the  occurrence  of  an  abortion  would,  in  all  probability, 
seriously  complicate  her  condition. 

Inflammation,  more  or  less  in  extent,  of  the  cellular  tissue  about 
the  uterus,  is  of  very  frequent  occurrence,  and  it  may  become 
so  blended  with  the  organ  as  to  make  it  difficult  to  judge  of  the 
exact  condition  of  the  uterus  itself.  The  history  of  the  case  will 
not  always  lead  us  to  suspect  the  complication  previous  to  making  the 
examination.  If  a  recent  attack  has  occurred,  the  finger  will  detect 
a  hard,  unyielding,  flat  surface  stretched  across  the  roof  of  the 
pelvis,  which  will  be  painful  on  pressure,  and  cannot  well  be  mistaken 
for  any  other  condition.  Although  the  uterus  will  always  be  some- 
what enlarged  from  the  inflammation  obstructing  the  circulation  of 
blood,  we  will  find,  by  the  aid  of  the  hand  over  the  abdomen,  that  the 
length  of  the  uterus  bears  no  proportion  to  the  size  of  the  mass  as 
indicated  by  the  finger  in  the  vagina.  To  be  able  to  detect  and 
appreciate  the  stage,  as  well  as  the  extent,  of  this  always  somewhat 
serious  complication  is  very  important,  since,  without  proper  care  in 
conducting  the  examination,  a  fresh  attack  may  be  brought  on. 

Hemorrhage  sometimes  occurs  in  the  pelvis  about  the  uterus,  form- 
ing a  hgematocele  which  it  may  be  difiicult  to  distinguish  from  the 
cellulitis  that  frequently  accompanies  it.  But  the  history  of  the  case 
■will  generally  indicate  the  suddenness  of  the  attack,  coming  on,  as  a 


68  POINTS    FOE    DIAGNOSIS. 

rule,  about  the  time  of  the  menstrual  period,  and  accompanied  by 
prostration  and  other  symptoms  indicative  of  a  loss  of  blood.  If 
recently  formed,  the  tumor  will  be  felt  softer  than  when  cellulitis  has 
occurred  alone  ;  its  shape  will  also  be  diiferent.  Some  depression  can 
always  be  detected  by  the  finger  between  the  mass  and  the  uterus,  as 
if  two  rounded  surfaces  were  lying  in  contact.  The  blood  begins  to 
accumulate  first  in  the  posterior  cul-de-sac,  as  the  lowest  point  to 
which  it  gravitates,  and  acquires  the  rounded  outline  of  the  cavity, 
which  never  occurs  with  cellulitis.  Again,  when  the  collection  is 
extensive,  the  hand  placed  over  the  abdomen,  with  the  finger  in  the 
vagina,  will  detect  the  mass  extending  off  to  one  side  in  a  flattened 
form,  above  the  point  for  cellulitis,  and  it  cannot  be  mistaken  for  the 
uterus.  In  this  condition,  we  must  also  exercise  great  delicacy  of 
touch,  and  leave  the  position  of  the  uterus  undisturbed  for  fear  of 
reproducing  the  hemorrhage. 

After  a  miscarriage  or  childbirth  the  uterus  may  remain  too  large, 
from  imperfect  involution.  The  organ  Avill  generally  be  found  movable, 
free  from  adhesions,  and  uniformly  hypertrophied  throughout.  The 
neck  will  frequently  be  found  lacerated  and  covered  with  an  extensive 
erosion,  and  the  uterine  canal  open,  and  with  a  profuse  leucorrhoea. 
The  history  of  the  case  will  likely  indicate  the  existence  of  some 
difficulty  following  a  previous  pregnancy,  after  which  menstruation 
became  either  scanty  or  too  free,  and,  as  a  rule,  more  painful.  The 
true  condition  will  be  easily  recognized,  and  the  most  important  point 
will  be  to  establish  the  cause  of  the  non-involution,  with  the  view  of 
instituting  the  proper  treatment.  "We  will  find  the  chief  causes  of 
non-involution  to  be  laceration  of  the  neck,  cellulitis,  displacement  of 
the  uterus  from  laceration  of  the  perineum,  and  prolapse  of  the  vaginal 
walls,  with  impairment  of  the  general  health. 

A  fibrous  tumor  should  never  be  mistaken  for  pregnancy,  since  the 
record  of  the  case,  with  rare  exceptions,  will  show  the  frequent  and 
irreo"ular  occurrence  of  hemorrhage  during  a  long  period  of  time.  If 
large  enough  to  occupy  any  portion  of  the  abdomen,  its  surface  will 
be  found  hard  and  irregular,  or  nodulated.  Occasionally,  we  may 
meet  with  a  case  of  fibrous  tumor  where  a  long  interval  occurs  without 
even  a  menstrual  show,  with  the  possibility  of  pregnancy  existing. 
Under  these  circumstances  we  must  have  all  doubt  as  to  the  condition 
removed  -before  we  make  any  attempt  to  reach  the  interior  of  the 
organ.  When  a  growth  is  being  developed  within  the  uterine  canal, 
or  nearer  that  surface  than  the  outer  one,  the  organ  may  be  uniform 
in  shape,  and  we  will  be  unable  to  arrive  at  any  definite  knowledge 


EXTKA-UTERINE    PREGNANCY.  69 

until  the  canal  can  be  dilated  by  a  sponge  tent  sufficiently  for  the 
introduction  of  the  finger. 

The  body  of  the  uterus  is  frequently  found  enlarged,  from  some 
obstruction  to  the  circulation,  in  females  who  have  never  been  preg- 
nant. Some  degree  of  flexure  above  the  vaginal  junction  often  exists 
in  these  cases,  and  likely  the  remains  of  a  previous  attack  of  cellulitis 
Avill  be  detected.  The  same  condition  is  found  with  women  who  have 
been  in  the  habit  of  taking  means  to  prevent  conception,  or  Avhen  sexual 
intercourse  has  not  been  properly  performed,  from  incapacity  on  the 
part  of  the  male,  or  wherever  the  laws  of  nature  have  been  violated. 

Without  a  knowledge  of  the  previous  history  of  the  case,  an  ovarian 
cyst  or  tumor  may  be  mistaken  for  pregnancy.  But  its  growth  is 
generally  of  much  longer  duration  than  the  term  of  pregnancy. 
Menstruation,  as  a  rule,  undergoes  but  little  change  ;  fluctuation  can 
be  detected  at  some  point  in  the  mass,  and,  from  the  vagina,  the  uterus 
can  generally  be  felt  of  a  normal  size,  lying  either  backward  or  for- 
ward under  the  tumor.  It  is  sometimes  difficult,  by  means  of  palpa- 
tion alone,  to  make  a  diagnosis  between  an  ovarian  cyst  and  a  fibro- 
cyst  of  the  uterus,  but  in  the  latter  condition  the  organ  is  generally 
found,  on  passing  the  probe,  to  be  very  much  enlarged. 

Extra-uterine  pregnancy  fortunately  is  of  rare  occurrence,  and  its 
existence  is  seldom  suspected  until  rupture  of  the  sac  takes  place. 
The  development  is  sometimes  retarded  beyond  the  usual  term  of 
gestation,  which  fact  may  lead  to  an  examination,  and  we  may  not  be 
able  to  detect  the  exact  condition,  since,  if  death  of  the  foetus  has 
taken  place,  an  attempt  of  nature  will  have  been  made  to  encyst  the 
whole  mass ;  but  we  will  find  the  uterus,  although  somewhat  enlarged, 
not  involved  in  the  mass,  unless  indirectly  from  the  occurrence  of 
cellulitis. 

Abscesses  in  the  cellular  tissue  of  the  pelvis,  between  the  broad 
ligaments,  and  in  the  substance  of  the  ovaries,  may  be  mentioned.  The 
history  of  each  case  will  give  evidence  of  constitutional  disturbance 
from  inflammation  and  the  formation  of  pus,  and  it  will  not  be  diffi- 
cult to  establish  the  fact  that  the  uterus  itself  is  not  involved. 

Cancerous  infiltration  of  the  tissues  of  the  pelvis,  and  deposits  of 
the  same  character  on  the  omentum,  need  only  now  be  referred  to,  as 
it  will  be  easy  to  ascertain  their  relation  with  the  uterus  and  other 
organs. 

After  obtaining  all  the  information  to  be  gained  by  a  digital  ex- 
amination, we  must  note  the  size  of  the  vagina  ;  prolapse  of  either 
wall ;  thickening  of  the  urethra  ;  or  tenderness  in  the  neighborhood  ; 


70  POINTS    FOE    DIAGXOSIS. 

and  -^'lietlier  there  has  been  laceration  of  the  permeum,  and  if  so,  the 
conditions  resulting  from  it.  There  "vvill  be  no  need  of  an  examination 
of  the  bladder  unless  some  point  in  the  history  of  the  case  should  in- 
dicate the  necessity. 

But  no  examination  is  complete  without  passing  the  finger  into  the 
rectum,  not  only  to  confirm  the  impressions  obtained  by  touch  from 
the  vasdna,  but  also  to  ascertain  the  condition  of  the  viscus  itself.  At 
the  entrance,  within  a  fold  of  the  sphincter,  an  unsuspected  fissure 
may  be  found,  which,  from  reflex  irritation,  may  cause  irritability  of 
the  bladder,  and  disturbance  of  the  circulation  in  the  pelvis,  leading 
to  dysmenorrhoea,  tenesmus,  prolapse  of  the  uterus,  leucorrhoea,  and 
conorestion  of  the  ovaries.  All  of  these  conditions  I  have  been  able 
to  trace  directly  to  the  presence  of  a  fissure  in  ano,  and  relief  has 
followed  its  cure.  A  fissure  is  always  accompanied  with  obstinate 
constipation,  a  condition  which,  if  not  relieved,  at  least  temporarily, 
will,  in  consequence  of  the  obstruction  to  the  circulation,  greatly 
retard  the  recovery  of  almost  every  case  of  uterine  disease.  The 
presence  of  a  rectal  polypus  will  also  cause  a  great  deal  of  reflex  irri- 
tation in  the  neighboring  organs.  But  the  great  advantage  of  a 
digital  examination  through  the  rectum,  is  the  facility  it  gives  us  to 
explore  portions  of  the  pelvis  out  of  reach  from  the  vagina.  We  can 
bring  within  range  of  the  finger  nearly  the  whole  posterior  Avail  of  the 
uterus,  if  of  normal  size,  and  any  enlargement  of  the  ovary  in  this  direc- 
tion can  be  detected.  The  extent  of  a  cellulitis  can  be  fully  mapped 
out,  and  we  can  judge  of  the  nature  of  growths  which  may  not  even 
have  been  suspected  from  a  vaginal  examination. 

The  late  Prof.  Simon  of  Heidelberg  has  so  far  appreciated  the  ad- 
vantage to  be  gained  from  a  rectal  examination,  that  he  was  in  the 
habit  of  introducing  the  whole  hand,  and  passing  even  beyond  the 
sigmoid  flexure.  I  have  succeeded  in  passing  my  hand  into  the  rec- 
tum several  times,  and  without  the  slightest  bad  result,  as  the  sphincter 
entirely  regained  its  power  in  a  few  days  ;  but  I  succeeded  in  gaining 
no  further  information  than,  nor  even  as  much  as,  I  could  with  one  or 
two  fingers  alone,  since,  from  the  cramped  position  of  the  hand,  there 
was  no  freedom  of  motion.  To  introduce  the  hand  it  is  always  neces- 
sary to  administer  an  anaesthetic.  If  this  is  done  I  can,  with  two 
fingers,  reach  well  up  to  the  sigmoid  flexure,  and  by  conjoined  mani- 
pulation make  a  still  more  thorough  exploration  of  the  pelvis.  As  the 
sigmoid  flexure  is  so  bound  down  I  cannot  divest  myself  of  the  con- 
viction that  it  is  dangerous  to  attempt  to  pass  beyond  it. 


DILATATION    OF    THE    URETIIRA.  71 

In  addition  to  this  mode  of  examination  by  the  rectum,  I  will 
refer  briefly  to  the  recent  iM-actice  of  exploring  the  bladder  and  ante- 
rior wall  of  the  uterus  by  introducing  the  finger  through  the  urethra. 
Prof.  Simon  used  a  graduated  series  of  dilators  of  conical  shape,  and 
recommended  that  the  passage  should  be  opened  rapidly.  I  have  used 
the  dilators,  and  have  also  employed  my  finger  alone  for  the  purpose ; 
I  have  brought  about  the  dilatation  rapidly,  and  I  have  accomplished 
it  gradually,  but  always  with  great  care.  In  my  book  on  A^esico- 
vaginal  Fistula,  published  in  1869,  I  deprecated  the  practice  of  di- 
lating the  urethra  for  the  removal  of  stone,  as  I  had  met  with  cases 
where  incontinence  of  urine  remained  afterwards.  I  have,  however, 
met  with  cases  Avhere  the  urethra  Avas  dilated  without  the  slightest 
difficulty,  and  with  no  incontinence  afterwards.  Again,  I  have  been 
so  unfortunate  as  to  lacerate  the  neck  of  the  bladder,  in  spite  of  all 
care,  and  without  the  slightest  premonition.  I  have  known  the  same 
accident  to  occur  in  the  hands  of  others.  For  the  present  it  is  only 
necessary  to  state  that,  as  a  means  of  diagnosis,  it  does  not  compen- 
sate for  the  risk:  by  means  of  the  conjoined  manipulation,  the  anterior 
wall  of  the  uterus  can  be  quite  as  thoroughly  examined  from  the 
vagina. 

Without  the  use  of  the  probe  we  cannot  always  be  sure  of  the  true 
direction  of  the  uterine  canal,  nor  of  the  relation  of  the  organ  itself  to 
external  growths.  The  instrument  may  be  introduced  while  the  patient 
is  lying  on  the  back,  the  finger  being  used  as  a  guide  to  the  os  uteri. 
But  I  prefer  to  introduce  it  after  bringing  the  cervix  into  view, 
although  it  may  be  frequently  necessary  to  turn  the  patient  again  on 
the  back.  The  mode  of  examination  with  the  probe  will  be  again 
referred  to,  after  describing  the  manner  of  using  the  speculum. 

After  completing  the  rectal  examination,  if  there  is  still  a  doubt  as 
to  the  relation  of  some  outgrowth  to  the  uterus,  Sims's  elevator  may  be 
used,  with  the  patient  on  the  back,  or  we  may  defer  its  use  until  after 
the  speculum  examination.  This  instrument  has  already  been  described, 
and  it  will  be  found  most  useful  for  releasing,  as  it  were,  the  uterus 
from  a  neighboring  mass.  The  organ  is  placed  so  perfectly  under 
control  of  the  operator  by  its  use,  that,  unless  the  uterus  be  so  much 
enlarged  as  to  admit  of  little  freedom  of  motion,  a  very  accurate 
estimate  can  be  formed  as  to  its  attachments. 


72  POINTS    FOR    DIAGNOSIS. 


Mode  of  Using  the  Speculum. 


Bringing  into  view  the  cervix  and  the  greater  portion  of  the  vagina, 
by  means  of  Sims's  perineal  retractor,  or  speculum,  is  eifected  not  so 
much  by  the  manner  of  holding  the  instrument,  as  by  placing  the 
patient  in  the  proper  position. 

She  is  to  lie  on  the  left  side  obliquely  across  the  table,  with  her 
lower  limbs  flexed,  so  that  her  head  and  knees  will  be  near  the  edge 
of  the  table,  to  the  right  of  the  operator,  and  her  hips  near  the  lower 
angle  on  the  opposite  side.  The  under  or  left  arm  should  be  drawn 
out  from  under  her,  and  flexed  across  the  back,  while  the  body  must 
be  rolled  over  on  the  chest  as  much  as  possible.  This  will  necessitate 
the  flexing  of  the  upper,  or  right,  leg,  until  the  knee  comes  in  contact 
with  the  table,  and  it  is,  therefore,  drawn  up  more  than  the  under  one. 
In  this  position  the  face  is  partially  turned  to  the  right,  and  the  head 
must  be  placed  on  a  level  lower  than  the  pelvis,  with  only  a  small 
pillow  under  it.  It  is  a  good  plan  to  have  the  legs  at  the  head  of 
the  table  about  three  inches  shorter  than  those  at  the  foot.  It  is 
very  convenient  to  have  a  foot-board,  which  can  be  draAvn  out  Avhen 
needed,  since  this  aff'ords  a  resting-place  for  the  feet  and  enables  the 
hips  to  be  placed  at  the  edge  of  the  table,  within  easy  reach  of  the 
operator. 

For  an  operation,  or  when  some  special  examination  is  to  be  made, 
it  is  necessary  that  all  the  clothing  should  be  made  loose  about  the 
waist.  When  this  has  been  done  the  vagina,  on  the  introduction  of 
the  speculum,  Avill  become  fully  opened  by  atmospheric  pressure 
and  the  action  of  gravity.  But  for  an  ordinary  examination  this 
preparation  is  not  necessary ,  and  when  the  cervix  is  not  exposed  at 
once,  it  can  be  brought  readily  into  view  by  other  means.  That  there 
may  be  no  unnecessary  exposure  a  sheet  must  be  thrown  over  the 
patient  by  the  nurse,  so  that  one  end  may  be  tucked  in  between  the 
legs  to  cover  the  upper  buttock,  and  the  lower  one  is  to  be  covered 
by  an  extra  napkin,  which  will  also  pi'otect  the  patient's  clothing. 

As  the  nurse,  with  her  left  hand,  draws  up  the  soft  parts  and  right 
labium,  the  operator  is  to  introduce  the  instrument,  well  lubricated 
and  guarded  by  his  index  finger,  which  must  occupy  the  length  of  the 
vaginal  portion  of  the  speculum.  After  the  speculum  has  been 
directed  into  the  hollow  of  the  sacrum,  the  soft  parts  are  to  be  firmly 
pressed  back,  by  the  thumb  and  index  finger  against  the  instnmient, 
which  is  to  be  thus  held  until  it  can  be  grasped  by  the  assistant.  If 
the  speculum  be  held  properly,  it  not  only  retracts  the  periiicuni,  but 


MODE  OF  USING  THE  SPECULUM.  73 

it  also  helps  to  elevate  the  upper  labium.  The  instrument  Is  not  to 
draw  back  the  perineum  in  a  line  with  the  coccyx,  but  to  make  traction 
to  the  right  of  it,  and  somewhat  obliquely  across  the  upper  buttock. 
By  placing  the  buttocks  close  to  the  angle  of  the  table,  the  assistant 
is  enabled  to  stand  sufficiently  behind  the  patient  to  steady  the 
instrument.  This  is  not  to  be  done  by  traction,  but  by  using  the 
width  of  the  hand,  placed  as  a  wedge  between  the  buttock  and  upper 
edge  of  the  speculum.  The  central  portion  of  the  instrument  lies 
against  the  flat  of  the  hand,  and  the  upper  part  in  the  sulcus  between 
the  thumb  and  index  finger,  so  that  the  fingers  are  free,  and  can  be 
moved  without  disturbing  the  position  of  the  speculum.  B}^  thus 
using  the  hand  as  a  wedge,  the  instrument  can  be  steadily  held  in 
place  for  hours,  during  a  long  operation,  without  cramping  the 
fingers.  It  adds  greatly  to  the  comfort  of  a  patient  to  have  the 
instrument  held  in  this  manner,  and  she  is  unable  to  relax  herself  so 
long  as  the  perineum  and  rectum  are  being  irritated  by  the  frequent 
jerking  Avhich  occurs  when  traction  is  made  by  the  fingers  alone, 
without  a  resting-place  for  the  hand,  as  I  have  described. 

Unless  each  article  of  clothing  about  the  waist  has  been  loosened, 
the  uterus  Avill  not  always  be  brought  into  view  on  opening  the  vagina 
with  the  speculum,  and  even  then  it  is  often  necessary  to  push  aside 
the  anterior  wall  with  the  depressor.  When  the  cervix  is  once  ex- 
posed, it  will  generally  remain  in  view  by  drawing  it  gently,  with  a 
tenaculum,  in  front  of  the  fold  which  has  been  depressed. 

We  are  now  to  examine  carefully  the  condition  of  the  raucous 
membrane  of  the  vagina  and  the  cervix.  From  the  appearance  and 
quantity  of  the  discharge  we  may  form  some  idea  of  the  extent  and 
location  of  disease  within  the  uterine  canal.  The  more  profuse  the 
secretion,  the  more  certain  we  may  be  that  its  source  is  below  the 
internal  os,  and  from  the  cervical  portion  of  the  canal.  In  every 
instance  where  the  female  has  had  an  abortion  produced  or  borne  a 
child,  the  cervix  must  be  carefully  examined  for  a  laceration  of  some 
form,  as  lacerations  are  the  most  common  cause  of  hypertrophy  of  the 
uterus.  If  an  erosion  exists,  it  will  probably  be  a  partially  healed 
laceration,  and  must  not  be  mistaken  for  what  is  commonly  termed 
"ulceration:''  it  is  but  an  excoriation,  caused  by  the  uterine  secre- 
tions flowing  over  the  parts. 

When  in  doubt,  after  a  digital  examination,  as  to  the  direction  of 
the  uterine  canal,  the  true  condition  can  be  ascertained  only  by  means 
of  the  uterine  probe.  This  instrument  should  be  given  a  curve  in 
accordance  with  the  supposed  direction  of  the  uterus,  and,  as  the 


74  MODE    OF    USIXG    THE    PROBE. 

cervix  is  being  steadied  by  means  of  a  tenaculum,  it  can  be  intro- 
duced into  the  canal.  If  resistance  to  its  passage  is  met  with,  we 
can  judge,  at  least,  if  the  general  direction  be  correct,  although  some 
change  in  the  curve  may  be  needed.  The  probe  can  be  withdrawn 
to  make  the  change  deemed  necessary,  and  this  should  be  done  until 
it  can  be  easily  passed  to  the  fundus.  This  will  enable  us  to  appre- 
ciate the  exact  direction  and  depth  of  the  canal.  This  instrument 
enables  us  to  crain  the  needed  information  without  doino;  harm  to 
the  patient.  If  we  wish  to  obtain  its  fullest  benefit,  it  is  to  be 
handled  simply  as  a  probe,  being  introduced  always  with  care  and 
great  delicacy  of  touch.  It  is  to  be  passed  with  as  light  a  hand  as  a 
surgeon  would  employ  in  probing  the  track  of  a  gunshot  wound,  that 
we  may  be  able  to  detect  changes  in  the  diameter  and  other  details  of 
the  surface  of  the  canal.  In  fact,  we  must  feel  with  it  as  if  the  instru- 
ment were  a  prolongation  of  the  index  finger,  and  if  pain  or  bleeding 
is  caused  by  its  use,  under  ordinary  circumstances,  the  result  must  be 
attributed  to  faulty  manipulation.  A  Simpson's  sound  is  of  no  value 
in  my  hands  for  any  purpose,  and  I  have  for  many  years  abandoned 
it  as  a  dangerous  instrument.  This  will,  doubtless,  be  regarded  as 
an  exaggei'ation  by  many  who  think  it  useful ;  but  let  any  one,  not 
biased,  train  himself  to  use  the  probe,  and  he  will  be  fully  compen- 
sated, in  finding  a  new  method  of  observation  open  to  him.  "When 
the  uterus  is  very  much  anteverted  or  flexed,  it  is  often  difficult  to 
pass  the  probe,  and  it  will  be  necessary  to  give  it  two  curves,  one  of 
which  must  be  quite  large,  for  the  perineum  would  be  in  the  way 
were  we  to  attempt  to  introduce  the  instrument  without  it.  When  we 
are  obliged  to  pass  the  probe  through  a  tortuous  canal,  it  is  often 
necessary,  after  advancing  a  certain  distance,  to  turn  the  patient  on 
the  back  without  removing  the  instrument.  Then  while  directing  it 
with  one  hand,  we  can  change  its  curve,  from  time  to  time,  by  pressing 
it  in  the  proper  direction,  against  the  side  of  the  vagina  or  cervix, 
with  the  index  finger  of  the  other  hand. 

There  are  two  conditions  always  to  be  borne  in  mind  when  we  are 
about  to  pass  the  probe,  and,  although  they  have  already  been  re- 
ferred to,  the  importance  of  the  precaution  warrants  their  repetition  ; 
"  be  satisfied  beforehand  that  neither  pregnancy  nor  cellulitis  exists." 
As  to  the  first  of  these  conditions,  we  may  be  in  doubt,  and  must, 
therefore,,  defer  the  examination  until  such  doubt  is  removed  ;  but  to 
overlook  the  existence  of  cellulitis  is  culpable.  When  there  has  been 
a  recent  attack  of  cellulitis,  or  if  tenderness  on  pressure  still  exists  in 
the  neighborhood,  the  instrument  should  not  be  introduced.     Again, 


DANGERS    OF    THE    PROBE.  75 

with  the  finger,  we  may  be  able  to  detect  the  products  of  inflammation 
remaining  in  the  forms  of  thickening,  but  without  tenderness  ;  in  such 
cases  the  probe  may  be  used  with  care,  but  we  must  scrupulously 
avoid  disturbing  the  position  of  the  uterus. 

]\Iany  a  poor  woman  has  had  to  suffer  from  the  carelessness  of  her 
physician  in  overlooking  a  latent  cellulitis,  and  endured  years  of  bad 
health,  and  often  permanent  sterility,  from  this  disease  being  re- 
kindled by  the  unskillful  use  of  the  probe  or  sound,  and  extending 
beyond  the  limits  of  the  first  attack. 


76       CAUSES  OF  DISEASE,  REFLEX  AND  DIRECT, 


CHAPTER    V. 

CAUSES  OF  DISEASE,  REFLEX  AND  DIRECT. 

Influence  of  ganglionic  or  sympathetic  system  of  nerves — Faulty  nutrition — Ute- 
rine congestion  and  inflammation — Effect  of  increased  weight  of  the  uterus — 
Influence  of  the  ovaries  upon  the  uterine  condition — Sub-involution — Constipa- 
tion— Influence  of  fruitfulness  and  sterility  upon  growths — Difi"erence  between 
a  fibroid  and  a  fibrous  tumor — Active  exercise  renders  the  uterus  less  liable  to 
conditions  arising  from  celibacy — Cancer  and  corroding  ulcer — Atrophy  of  ute- 
rine body — Accidental  causes  of  disease  :  1.  Products  of  inflammation  p.nd  hemor- 
rhage— 2.  Injuries  of  the  cervix  and  displacements — 3.  Injuries  of  the  vagina 
and  its  outlet — 4.  Results  of  inflammation  of  mucous  glands  of  the  vagina, 
uterus,  Fallopian  tubes,  and  ovaries. 

During  childhood,  the  female  organs  of  generation  are,  as  a  rule, 
exempt  from  disease.  But  from  constitutional  causes,  from  exposure 
or  accident,  inflammation  of  the  mucous  membrane  of  the  vagina  and 
outlet  sometimes  occurs.  In  rare  instances,  tumors  of  the  ovary  and 
uterus  are  developed  before  puberty  as  a  consequence  of  perverted 
nutrition. 

The  exciting  causes  of  disease  during  the  developing  stage  of 
puberty  are  hereditary  or  acquired  fulness  of  body,  causing  absence 
or  arrest  of  local  development,  and  disorders  of  the  nervous  system 
from  impaired  general  nutrition.  The  diseases  of  married  life  are  to 
be  traced  chiefly  to  the  consequences  of  sterility  and  to  the  accidents 
of  child-bearing. 

During  the  natural  change  of  life,  and  at  the  cessatiom  of  menstrua- 
tion, disorders  of  the  nervous  system  are  very  common,  reacting  on 
organic  life  until  harmony  of  function  is  restored,  or  until  the  disturb- 
ing influences  of  new  growths,  due  to  perverted  nutrition,  shall  have 
passed  away.  Finally,  when  all  ovarian  activity  has  ceased,  and 
atrophy  has  taken  place,  the  organs  of  generation  become  quiescent, 
and,  as  in  childhood,  are  only  liable  to  diseases  of  the  mucous  mem- 
brane from  ordinary  causes. 

The  sympathetic,  or  ganglionic,  nervous  system  is  the  regulator  of 
organic  life,  and  the  great  source  of  nerve  force  by  which  harmony  of 
action  is  preserved  after  the  motor  power  and  sentient  life  have  been 
perfected.     Wlien  in  perfect  action  we  have  health,  wlien  impaired 


IXFLUEXCE    OF    QAXGLIONIO    SYSTEM    OF    NERVES.  77 

disease,  and  when  its  function  ceases  death  results.  It  is  sufficient  for 
our  present  purpose  to  note  its  close  relation  with  the  function  of 
nutrition.  We  see  its  connection  with  the  circulation  of  the  blood  to 
such  a  degree  that,  to  the  smallest  capillary,  the  vessels  are  covered 
with  a  network  of  its  nerve  filaments  communicating  directly  with  the 
common  centres.  This  nerve  force  unquestionably  excites  the  heart 
to  action  and  the  arteries  to  contract,  but  it  is  doubtful  if  the  heart 
has  the  power  to  drive  the  blood  through  the  capillaries,  except  by 
direct  local  stimulation  of  these  nerve  filaments  by  a  healthy  condition 
of  the  blood  itself.  With  impaired  nutrition,  the  blood  will  be  defi- 
cient in  the  elements  essential  to  this  stimulus,  and,  as  a  consequence, 
the  circulation  becomes  sluggish,  and  the  venous  capillaries  con- 
gested. Therefore,  when  a  condition  has  been  reached,  which  we  are 
able  to  recognize  as  disease,  we  may  assert  that  impaired  nutrition, 
as  the  cause,  and  not  as  the  effect,  depreciates  the  nervous  force, 
without  the  full  expression  of  which,  functional  derangement  naturally 
follows.  Again,  from  some  unknown  cause,  the  necessary  nerve  force 
becomes  insufficient  for  the  requirements  of  organic  life,  and  the  nutri- 
tive functions  are  the  first  to  suffer.  Although  nutrition  is  subordinate 
fully  to  the  influence  generated  from  the  ganglionic  centres,  yet,  by 
a  law  of  mutual  dependence,  this  nerve  force  cannot  exercise  a  healthy 
co-operation  so  long  as  nutrition  is  defective.  When  this  balance  is 
lost,  we  have  local  disease  established  at  the  weakest  point  in  the 
body,  whenever,  from  other  causes,  the  organ  is  unable  to  protect 
itself.  It  is  with  the  effect  we  have  chiefly  to  deal,  since  beyond 
a  certain  point  we  cannot  go  in  our  speculations  as  to  the  exciting 
cause  of  disease,  for  the  mysteries  of  life,  the  commencement  of 
disease  and  of  death,  must  ever  remain  beyond  the  limits  of  our 
appreciation. 

From  our  present  want  of  accurate  knowledge  on  many  points  of 
pathology,  it  has  been  found  to  be  a  difficult  matter  to  form  any 
classification  of  the  diseases  of  women  which  would  be  free  from  ob- 
jection. 

To  illustrate  my  own  views,  I  Avill  assume  for  convenience  that  these 
diseases  originate  from  causes  to  be  attributed  either  to  faulty  nutrition 
or  to  accident. 

The  first  classification,  "  from  faulty  nutrition,"  may  be  subdivided 
into  congenital  and  acquired  causes.  Under  the  head  of  congenital 
causes  we  may  place  an  inherited  feeble  organization,  arrest  of  growth 
and  absence  of  development  before  puberty,  since,  doubtless,  these  do 


78       CAUSES  OF  DISEASE,  REFLEX  AND  DIRECT. 

tend  to  render  the  female  more  liable  to  disease.  The  acquired  causes 
of  disease  are  to  be  traced  directly  to  faulty  nutrition  from  which  the 
balance  was  lost,  after  puberty,  between  waste  and  repair,  leading  to 
organic  and  functional  derangement.  From  this  loss  of  balance  we 
have  disturbances  in  the  circulation  producing  hypertrophy  or  atrophy 
of  tissues  already  formed,  or  the  development  of  new  growths,  as 
tumors  and  malignant  diseases. 

Diseases  from  accidental  causes  result  chiefly  from  the  various  in- 
juries of  childbirth,  or  from  inflammatory  action. 

The  girl  is  liable  to  the  consequences  of  a  feeble  organization  in- 
herited from  her  parents,  unless  she  be  surrounded  before  puberty 
by  circumstances  well  fitted  to  remedy  the  defect.  Fortunately  she 
is  more  likely  to  inherit  the  general  physical  tendency  of  her  father 
as  well  as  his  intellectual  force,  but,  as  to  her  sexual  development, 
she  will  certainly  be  more  liable  to  uterine  disease  if  her  mother  has 
been  a  sufferer  in  that  direction.  There  are  many  exceptions  to  the 
rule,  however,  influenced  by  the  relative  ages  of  the  parents  to  each 
other,  as  well  as  by  the  age  of  the  mother  at  parturition.  The 
daughter,  if  the  eldest  child,  is  less  liable  to  local  difficulties  than  she 
would  be  if  born  after  other  children,  when  her  mother's  health  may 
have  already  begun  to  sufier.  The  young  girl  with  a  feeble  organiza- 
tion will,  as  a  rule,  menstruate  for  the  first  time  at  an  early  age, 
unless  careful  attention  has  been  paid  through  childhood  to  the  proper 
physical  training.  This  precocious  growth  is  commonly  attended  by 
undue  nervous  development,  so  that  the  female  is  almost  certain  to 
suff'er  at  a  later  period  of  life  from  some  derangement  of  the  organs 
of  generation,  as  the  result  of  faulty  nutrition. 

An  arrest  of  uterine  growth  may  occur  in  embryo  without  reference 
to  the  development  of  the  ovaries,  so  that  the  cornua  uteri  may 
remain  separated,  or  the  vagina  absent  or  imperfectly  developed. 
But  when  the  ovaries  have  reached  a  certain  degree  of  develop- 
ment, the  further  growth  of  the  uterus  becomes  dependent  on  them. 
Therefore,  without  the  proper  ovarian  influence,  the  uterus  will 
remain  under  size,  although  in  shape  it  may  have  been  perfectly 
formed.  The  ovaries  may  hav-e  attained  a  stage  of  development  per- 
mitting of  ovulation,  yet,  from  some  defect  of  vitality  in  the  perfect 
maturity  of  the  ovules,  the  process  does  not  ofifer  the  proper  stimulus 
to  the  uterus,  and  arrest  of  growth  may  take  place  at  any  time  short 
of  the  full  development  of  the  organ. 

Defects  in  development  may  be  illustrated  by  the  existence  of  a 


CLASSIFICATION    OF    CAUSES    OF    DISEASE. 


79 


o 


^ 

o 

^ 

x: 

— 

o 

5 

> 

. 

c 

t; 

*A 

O 

*-» 

,'^ 

S 

>. 

•p 

w 

O 

^ 

OJ 

rf 

p. 

p. 

■" 

- 

•f^ 

3 

o 

- 

o 

i- 

tr 

= 

3 

r1 

"5 

■- 

■i 

■^ 

b 

o 

p. 

ij 

P. 

rt 

^ 

c 

•r 

t^ 

v:" 

3 

^ 

o 

<~ 

T3 

"2 

o 

- 

,a 

d  :: 


-sis 


O    C3    P  *-    O 


f^ 


goo 


,>- 

cj 

d 

1 

is 

t^ 

X 

:2 

o 

s 

o 

o 

a 

p. 

3 

rt 

" 

~ 

6 

"" 

a 

=  Ji  a 

o  a  " 

I.    0-? 

5 '-5 


o 

fi 

CD 

p. 

a 

H 

-a 

a 

d 

> 

— 

m 

o 

O 

^ 

i; 

== 

c 

Lf. 

a 

^3 

^1 

<  _3  -2  ■_ 

e3  5  3 


cj  2  =  o  cs  o 
al  2-1^0.1 

^r;  ^  =  a  B-p 

^  a  a  =  =  =i^ 
»!  i^  ;3  ;  o  o  o 
|='SllS2 

C  g  o  ^»  ^  a  g 


-  2  >.~ 


ei  « 

II 

C  5" 

ri  3 

o    ^    t-    » 


t> 

■" 

dj 

tf 

rt 

o 

* 

o 

K 

'r 

r^' 

;3 

t 

a 

- 

o 

<; 

" 

:i 

o 

" 

o 

o 

ll 

o 

o 

- 

ri 

-1 

- 

— 

.- 

■d 

■p 

^ 

a> 

c 

2 

= 

<; 

a 

o 

80       CAUSES  OF  DISEASE,  REFLEX  AND  DIRECT. 

double  uterus  and  a  double  vas-ina,  a  double  uterus  with  a  sino-le 
vagina,  or  a  single  uterus  with  a  double  vagina.  The  vagina  may  be 
divided  bj  a  fissure  extending  partially  or  entirely  through  its  length, 
or  an  impervious  septum  may  exist,  as  I  have  seen,  across  its  diameter, 
forming  with  the  hymen  two  closed  cavities.  There  may  also  be 
a  cleft  of  the  whole  urethra,  of  which  I  have  seen  but  one  case, 
and  of  the  recto-vaginal  septum  with  absence  of  the  perineum,  a 
defect  in  development  not  infrequently  found.  I  may  also  mention 
a  common  defect  in  shape  of  the  vagina,  the  importance  of  Avhich 
is  not  fully  recognized :  it  is  where  the  posterior  cul-de-sac  is  absent, 
causing  retroversion  and  subsequent  flexure.  An  undue  development 
in  length  of  the  cervix  uteri  at  the  expense  of  its  width,  is  a  common 
defect,  from  which  either  retroversion  or  a  flexure  of  the  uterine  neck 
at  the  vaginal  junction  may  take  place.  The  defect  in  the  shape  of 
the  vagina,  and  the  misdirected  development  of  the  cervix  are  always 
found  in  connection  with  impaired  nutrition,  induced  by  the  over- 
taxing or  misapplying  of  the  nerve  force.  Either  condition  may  be 
found  in  the  young  girl  who  has  broken  down,  after  having  succeeded 
in  completing  her  education,  at  a  time  when  nature  was  making  every 
effort  to  perfect  the  growth  of  the  organs  of  generation.  Such  a  per- 
version of  nerve  force — this  building  up  of  a  brain  out  of  season — 
.will  always  entail  a  defect  of  sexual  development.  Whenever  a 
young  girl,  during  the  developing  period  of  puberty,  or  previous 
to  its  completion,  has  been  burdened  with  care  or  responsibility,  or 
whenever  her  nervous  system  has  been  over-taxed  from  any  other 
cause,  and  at  the  expense  of  nutrition,  there  will  always  result 
some  such  perverted  or  arrested  development.  There  is  often  an 
arrest  of  growth  in  the  ovaries  and  uterus,  as  well  as  defects  in 
their  development,  and  nature  enters  many  a  protest  before  she 
ceases  from  her  efforts  to  repair  the  injury.  I  have  known  many 
girls  who  commenced  their  menstrual  life  free  from  pain,  and  in  good 
health,  and  did  not  suffer  until  after  they  had  begun  to  impair  their 
nervous  system  by  over-study.  A  physical  examination  in  these  cases 
enabled  me  to  detect  a  condition  of  flexure  of  the  cervix,  causing  a 
dysmenorrhoea,  which  could  not  have  existed  at  the  beginning,  as  the 
menstrual  flow  was  then  free  from  pain. 

In  regard  to  absence  of  development,  that  of  the  vagina  is  the  one 
most  commonly  found.  It  has  been  questioned  if  the  uterus  is  ever 
entirely  wanting,  authorities  holding  that  one  if  not  both  cornua 
always  exist,  at  least  in  a  rudimentary  form.  But  I  have  met  with 
a  number  of  instances  where  it  was  impossible,  by  any  means  of  ex- 


CONGESTION.  81 

ploration,  to  detect  the  slightest  evidence  of  the  existence  of  the  uterus 
in  any  form,  and  in  these  cases  the  vagina  was  always  absent.  I  have 
never  met  with  an  instance  Avhere  I  could  satisfy  myself  that  the 
ovaries  were  wanting,  since  the  general  physical  condition  always 
indicated  at  least  their  partial  development. 

The  effect  of  faulty  nutrition,  acquired  after  puberty  from  a  loss  of 
balance  between  Avaste  and  repair,  will,  to  a  great  extent,  occupy  our 
attention  as  the  chief  factor,  or  exciting  cause  of  disease.  Under  the 
first  head  we  will  consider  the  effects  of  derangement  in  the  circula- 
tion, producing  hypertrophy  or  atrophy  of  tissues  already  formed,  with 
displacements  and  flexures  of  the  uterine  body. 

Congestion  produces  fulness  and  expansion  of  the  tissues,  and  this 
condition  of  the  circulation  may  remain  passive  or  result  in  inflamma- 
tion, while  a  Avant  of  nutrition,  from  lessening  the  supply  of  blood, 
causes  atrophy.  Arterial  congestion,  the  result  of  some  local  irrita- 
tion, is  a  condition  always  temporary  in  duration  Avhen  the  reparative 
powers  are  in  a  state  of  integrity.  Congestion,  however,  does  not 
imply  inflammation,  although  the  latter  cannot  have  a  beginning 
without  it.  If  the  arterial  congestion  reaches  a  degree  sufficient  to 
establish  inflammation,  there  will  be  instituted  a  distinct  train  of 
symptoms,  consequent  upon  and  secondary  to  the  primary  condition. 
It  is  necessary  at  the  outset  to  appreciate  the  marked  diff'erence 
between  passive  congestion,  which  is  generally  venous,  and  inflamma- 
tion. These  terms  are  usually  regarded  as  synonymous,  but  errone- 
ously so,  as  are  many  in  connection  with  uterine  disease.  Inflamma- 
tion cannot  exist  without  molecular  death,  and  its  products  are  easily 
recognized  until  absorbed.  We  may  look  in  vain,  after  death,  for  any 
evidence  of  an  existing  endometritis,  so  called,  or  for  an  ulceration  of 
the  cervix,  as  it  is  termed,  for  neither  of  these  conditions  is  inflam- 
matory. We  always  find  the  tissues  blanched,  the  blood  from  the 
capillaries  having  passed  into  the  larger  vessels,  as  the  heart  failed  in 
keeping  up  the  supply,  and  there  will  be  detected  neither  loss  of  tissue 
on  the  surface  of  the  mucous  membrane  beyond  the  epithelium,  if 
even  to  that  extent,  nor  any  hyperplasm  in  the  organ  itself.  Inflam- 
mation can  exist  only  in  an  acute  form,  although  its  products  may  re- 
main for  an  indefinite  period.  Therefore,  the  term  chronic  inflam- 
mation is  a  misnomer,  and  only  serves  to  give  eiToneous  impressions 
of  the  pathology  and  treatment  of  viterine  disease.  Inflammation  of 
the  uterine  body  never  occurs  except  after  parturition,  and  those 
conditions  which  are  commonly  held  to  be  the  direct  results  of  inflam- 
mation are  due  wholly  to  obstructed  circulation  in  the  organ,  caused 
6 


82        CAUSES  OF  DISEASE,  KEFLEX  AND  DIRECT. 

by  pathological  processes  in  the  cemx  and  neighboring  parts.  In 
this  way  are  to  be  accounted  for  the  so-called  uterine  hyperplasias 
"with  their  attendant  leucorrhoea. 

The  uterus,  being  an  erectile  organ,  and  surrounded  by  a  mass  of 
bloodvessels  passing  in  every  direction  through  the  loose  connective 
tissue  of  the  pelvis,  is  directly  affected  by  any  increase  or  diminution 
in  the  neighboring  circulation.  We  must  appreciate  the  fact  that  in 
no  other  part  of  the  body  have  we  such  a  network  of  vessels  within 
the  same  space.  In  consequence  of  the  erectile  character  of  all  the 
tissues,  these  vessels  in  time  become  varicose,  or  over-distended,  fi'om 
any  continued  obstruction  to  the  circulation,  and  have  an  almost  in- 
credible venous  capacity.  As  a  stream  will  saturate  the  ground  and 
lose  itself  in  a  marsh,  so  will  the  circulation  through  the  pelvic  cellu- 
lar tissue,  and  in  diseased  condition,  become  equally  sluggish.  The 
resemblance  is  a  closer  one  than  would  be  indicated  by  a  metaphor. 
For,  in  attempting,  after  death,  to  fill  by  injection  the  vessels  in  the 
pelvis  of  a  female  who  has  long  suffered  from  uterine  disease,  it  will 
be  found  that  the  distinctive  form  of  the  veins  is  frequently  lost  at 
different  points,  and,  with  all  care,  the  injections  will  become  extrava- 
sated  and  diffused.  With  due  allowance  for  the  supposition  that  rupture 
would  likely  occur  from  an  injection,  when  extravasation  would  not 
take  place  during  life,  it  is  proved  that  these  veins  become  gradually 
stretched  at  different  jDoints  out  of  all  form,  and  become  mere  recepta- 
cles. In  this  over-distended  condition  of  the  veins,  the  contractility 
has  been  lost  from  impaired  nutrition,  and  they  are  no  longer  able  to 
return  to  the  general  circulation  the  same  quantity  of  blood  received 
by  them  from  the  arterial  capillaries. 

The  uterus  must  settle  lower  in  the  pelvis  from  any  increase  in 
weight  and  from  traction,  and,  in  consequence  of  the  prolapse,  the 
difficulty  will  be  augmented,  since  the  veins  are  more  easily  com- 
pressed than  the  arteries.  Should  the  obstruction  continue  to  increase 
the  prolapse,  the  uterus  Avill  become  retro  verted  on  reaching  a  given 
point  in  the  vagina,  by  sliding  forward  in  the  direction  of  the  vaginal 
outlet.  This  Avill  occur,  although  the  uterus  may  have  been  ante- 
verted  in  the  beginning.  When  the  obstruction  has  been  confined  to 
one  side,  so  as  not  to  cause  general  enlargement,  the  organ  will  be- 
come flexed  upon  the  comparatively  healthy  side,  but  when  the  ob- 
struction is  limited  more  to  the  fundus  (and  it  is  the  more  common 
form),  the  flexure  will  be  on  the  diseased  side.  As  soon  as  the  weight 
of  the  flexed  uterus  causes  it  to  settle  in  the  pelvis,  the  circulation 
becomes  still  more  obstructed,  Avitli  the  same  consequences  as  attend 


CONGESTIVE  HYPERTROPHY.  83 

congestive  hypertrophy  alone.  An  anteflexure  of  the  uterine  body 
may  exist,  and,  if  the  organ  should  become  heavy  enough  to  reach 
the  proper  point  in  the  pelvis,  the  uterus  will  be  retroverted,  and  even 
this  version  changed  into  a  retroflexion. 

The  simplest  form  of  congestive  hypertrophy  may  be  illustrated  by 
the  condition  sometimes  found  in  a  woman  who  has  never  been  im- 
pregnated, where  it  exists  as  if  it  were  a  protest  on  the  part  of  nature, 
the  true  function  of  the  uterus  never  having  been  fully  called  into  play. 
Few  unmarried  women  reach  the  age  of  thirty-five  without  suffering 
more  or  less  from  this  condition  whenever  the  function  of  nutrition 
becomes  impaired  from  the  nervous  disturbance  Avhich  is  likely  to  be 
the  earliest  manifestation.  If  nutrition  improves,  this  condition  dis- 
appears, and  the  system  becomes  reconciled,  as  it  were,  to  the  state 
of  celibacy.  When  this  equilibrium  is  not  established,  some  perma- 
nent uterine  disease  is  likely  to  be  set  up,  generally  in  the  form  of  a 
fibrous  tumor. 

"We  meet  with  congestive  hypertrophy  accompanying  sterility,  which 
is  also  a  protest  of  nature.  This  condition  wall  be  found  whenever 
the  laws  of  nature  have  been  persistently  violated,  by  means  taken  to 
prevent  conception,  or  where  the  act  of  intercourse  has  been  im- 
properly performed.  The  common  cause  is  the  use  of  the  condom  or 
other  means  by  which  the  semen  is  excluded  from  the  vagina,  since  its 
presence  is  doubtless  the  natural  stimulus  for  relieving  the  congestion 
of  the  female  organs  of  generation.  Congestive  hypertrophy  also 
occurs  in  the  female  who  has  been  the  victim  of  an  ill-assorted  mar- 
riage, in  prostitutes,  and  possibly  in  those  addicted  to  self-abuse. 
Yet  I  must  record  the  result  of  a  large  experience,  to  the  credit  of  the 
sex,  by  stating  that  I  have  never  met  with  a  case  of  self-abuse  in  the 
adult  woman,  which  could  not  be  traced  to  disease  as  the  cause  and 
not  the  effect.  I  have  met  Avith  instances  of  congestive  hypertroph}^ 
due,  I  thought,  simply  to  the  fact  that  the  female  was  a  wife  without 
the  healthy  influence  of  having  been  a  mother.  In  these  cases  no 
cause  could  be  detected  for  the  sterility,  and  which,  therefore,  infe- 
rentially,  could  only  be  due  to  some  defect  in  development,  or  to  ob- 
struction in  the  Fallopian  tubes.  The  condition  of  the  Fallopian  tubes 
of  course  could  not  be  determined,  but  ovulation  certainly  took  place. 
In  the  absence  of  any  positive  knowledge,  it  was  supposed  that  the 
process  of  ovulation  in  these  cases  was  so  far  wanting  in  vitality  as  to 
fail,  not  only  m  rendering  conception  possible,  but  even  in  generating 
the  healthy  ovarian  influence. 

Some  may  claim  that  the  existence  of  passive  congestive  hyper- 


84       CAUSES  OF  DISEASE,  REFLEX  AND  DIRECT. 

trophy  of  the  uterus  is  due  and  secondary  to  some  abnormal  condition 
in  the  ovaries.  The  ovaries,  except  during  pregnancy,  exercise,  un- 
questionably, a  very  important  influence  upon  the  uterus  throughout 
the  sexual  life  of  the  female,  without  which  it  cannot  fully  perform 
its  function.  Yet  hypertrophy  of  the  uterus  is  often  found  to  exist 
long  before  any  abnormal  condition  of  the  ovaries  can  be  detected. 
Ultimately,  however,  if  the  hypertrophy  continues,  disturbance  in  one 
or  both  ovaries  will  become  manifested  by  pain  and  enlargement,  and 
even  prolapse  may  ensue,  a  result  secondary  to  the  uterine  condition, 
so  far  as  we  have  any  means  of  judging  between  cause  and  effect. 
These  facts,  and  others  derived  from  a  long  and  close  study  of  such 
cases,  lead  me  to  believe  that  the  uterine  nutrition  and  function  cannot 
be  dependent  solely  on  the  influence  of  the  ovaries.  The  ovaries  are 
able,  doubtless,  to  perform  their  function  in  the  absence  of  the  uterus, 
while  the  converse  is  impossible,  and  thus  the  subordinate  relation  of 
the  uterus  to  the  ovaries  is  shown.  Both  are  dependent  for  their  nerve 
force  on  the  solar  plexus,  in  common  with  all  the  organs  of  the  body, 
but  I  believe  the  view  which  has  been  advanced  by  some  observer  will 
be  found  correct,  that  they  are  both  under  the  influence  of  a  special 
ganglion.  If  this  be  true,  with  a  mutual  dependence,  under  certain 
circumstances,  on  each  other,  but  both  subordinate  to  a  common 
governing  influence,  a  morbid  condition  may  exist  separately  in  either 
the  ovaries  or  uterus  Avithout  necessarily  involving  the  other. 

The  condition  termed  sub-involution,  where  the  uterus  remains  too 
large  after  childbirth,  is  one  due  to  faulty  nutrition,  the  reparative 
powers  having  been  checked  in  the  process  of  removing  the  old  mate- 
rial. The  weight  of  the  uterus  acts  as  an  additional  source  of  irrita- 
tion, as  soon  as  the  female  attempts  to  exercise,  and  we  have  the 
hypertrophy  increased  by  passive  congestion.  There  are  many  of 
these  cases  where  the  arrest  of  repair  might  be  traced  to  the  enfeebled 
general  condition  of  the  female,  and  due,  therefore,  strictly  to  faulty 
nutrition.  But  in  my  experience  the  number  from  this  cause  is  by  no 
means  so  great  as  generally  supposed,  since  the  faulty  nutrition  is 
often  the  effect  and  not  the  cause.  This  will  be  treated  of  at  greater 
length  under  the  head  of  accidental  causes,  where  the  arrest  of  invo- 
lution is  considered  due  to  the  mechanical  effect  resulting  from  lacera- 
tion of  the  cervix,  and  displacement  of  the  uterus,  In  consequence  of 
laceration  of  the  perineum. 

I  have  frequently  met  with  congestive  hypertropliy  among  females 
who  had  lived  in  some  of  the  malarial  districts  of  the  Southern  States. 
This  enlargement  of  the  uterus  remained  as  one  of  the  sequelae  of 


NEW    GROAVTIIS.  85 

repeated  attacks  of  intermittent  fever  after  the  condition  of  the  gene- 
ral system  had  become  impaired.  The  venous  congestion  of  the  pelvis, 
with  the  enlargement  of  the  uterus,  was  brought  about  after  the  vessels 
had  lost  their  tone,  from  the  frequent  backing  up  and  obstruction  to 
the  return  cii'culation  through  the  portal  system. 

Habitual  constipation  and  errors  in  dress,  causing  obstruction  to  the 
venous  circulation  of  the  pelvis,  will  be  found  in  practice  to  be  fre- 
quent causes  of  congestive  hypertrophy  of  the  uterus.  The  obstruc- 
tion to  the  circulation  is  at  first  purely  a  mechanical  one,  but  at  length 
the  coats  of  the  vessels  lose  their  tone,  and,  having  become  habitually 
over-stretched,  the  difficulty  is  likely  to  remain  long  after  the  cause 
is  removed. 

We  will  consider  briefly  the  development  of  new  growths  as  the 
result  of  acquired  faulty  nutrition,  due  to  the  loss  of  balance  between 
the  waste  and  repair.  So  long  as  the  uterus  is  kept  properly  occu- 
pied with  its  legitimate  function,  this  balance  is  rarely  lost.  The 
female  who  has  passed  her  life  in  a  state  of  celibacy  is  more  liable, 
after  the  age  of  thirty,  to  suffer  from  the  development  of  a  fibrous 
tumor  than  the  sterile,  or  the  woman  who  has  borne  children,  while 
the  sterile  is  more  liable  than  the  fruitful  woman.  At  the  same  time, 
the  female  who  has  borne  children  is  not  exempt  from  these  growths, 
but  she  generally  sutlers,  as  a  rule,  after  she  has  been  rendered  sterile 
from  some  other  cause. 

It  is  necessary  to  make  an  explanation  of  the  difference  between  a 
fibroid  and  a  fibrous  tumor.  A  single  or  isolated  fibroid  may  become 
established  in  the  uterine  wall  of  a  sterile  woman,  acting  mechanically 
as  the  cause  of  her  sterility,  or  her  sterile  condition  may  have  resulted 
from  some  other  cause.  But  from  the  fact  of  her  being  a  wife,  such 
a  crrowth  will  be  held  somewhat  in  check.  The  unmarried  woman, 
however,  leading  a  life  contrary  to  the  design  of  nature,  can  have  no 
outlet  for  the  nerve  force  which  is  being  constantly  directed  to  her 
uterus.  She  may  have  a  fibroid  developed  because  she  has  never 
been  impregnated,  but  without  the  advantage  of  the  sterile  woman, 
with  whom  the  superfluous  nerve  force  may  be  partially  spent  in 
sexual  intercourse.  Therefore,  in  the  unmarried  female  the  whole 
force  of  this  state  of  perverted  nutrition  is  directed  to  the  growth  of 
a  fibrous  tumor,  which  we  may  consider,  for  our  purpose,  to  consist  of 
many  fibroids. 

When  the  unmarried  female,  from  necessity  or  inclination,  has  had 
her  nervous  energies  somcAvhat  expended  through  other  channels,  in  a 
steady  occupation  of  mind  or  body,  the  uterus  is  less  liable  to  suffer 


86       CAUSES  OF  DISEASE,  REFLEX  AND  DIRECT. 

from  the  state  of  celibacy.  Thus  the  servant  girl,  when  well  fed  and 
protected  from  the  effects  of  exposure,  is  far  less  liable  to  suffer  from 
the  development  of  a  fibrous  tumor,  or  from  a  fibroid,  than  the  female 
who  passes  her  life  under  circumstances  better  fitted  for  the  generation 
of  nervous  force,  but  without  proper  means  for  its  expenditure. 

The  woman  Avho  has  passed  through  the  period  of  sexual  life  in 
perfect  health,  with  all  her  superfluous  nerve  force  fully  absorbed  in 
the  legitimate  channel  of  childbearing,  is  more  liable  to  suffer  from 
perverted  nutrition  in  the  development  of  some  form  of  malignant  dis- 
ease, when  a  change  of  life  takes  place.  Sarcoma  may  occur  at  any 
time  during  the  active  sexual  life  of  a  female,  and,  with  but  one  or 
two  exceptions,  in  the  few  cases  I  have  met  with,  this  condition  had  been 
preceded  by  the  presence  of  a  fibroid.  In  these  cases  the  disease  has 
occupied  the  locality  of  the  tumor,  and  has  originated,  apparently, 
from  some  change  taking  place,  as  the  result  of  perverted  nutrition  in 
the  tumor  itself.  This  disease  is  rarely  found  in  the  female  who  has 
borne  children ;  at  least  I  have  never  met  with  it  except  in  the  un- 
married and  sterile.  Epithelioma,  on  the  contrary,  is  a  condition  found 
developed  in  the  woman  who  has  been  unusually  healthy,  and,  as  a 
rule,  who  has  given  birth  to  a  number  of  children  beyond  the  average. 
I  find  from  my  note-books  that  in  private  practice  I  have  never  seen 
an  instance  of  this  disease  in  the  sterile  or  unmarried  female.  All 
had  been  impregnated  and  borne  children  to  full  time,  except  two 
who  had  suffered  from  criminal  abortion  early  in  life,  and  were  sterile 
afterwards.  In  public  hospital  practice,  however,  I  find  recorded  the 
histories  of  several  females  suffering  from  this  disease,  who  claimed  to 
have  been  unmarried,  and  consequently  would  have  denied  a  preg- 
nancy. As  there  existed  no  object  to  deceive  among  the  class  of 
cases  treated  in  private  practice,  it  may  be  accepted  as  a  fact  that 
epithelioma  is  rarely,  if  ever,  found  in  the  female  Avho  has  never  been 
impregnated.  Epithelioma  and  corroding  ulcer  are,  as  a  rule,  de- 
veloped rather  late  in  life — the  latter  generally  before  the  natural 
cessation  of  menstruation,  and  the  former  after  it  has  ceased.  I  have 
never  met  with  a  case  of  corroding  ulcer  before  tlie  age  of  thirty-five, 
but  epithelioma  I  have  seen,  as  an  exception,  as  early  in  life  as  the 
age  of  twenty-three.  From  studying  the  histories  of  tliese  cases  I  am 
impressed  Avith  the  belief  that  the  exciting  cause  may  some  day  be 
traced  to  a  local  irritation,  set  up  in  consequence  of  injury  resulting 
from  childbirth,  most  likely  from  laceration  of  the  cervix. 

Atrophy  of  the  uterine  body  and  cervix  begins  to  take  place  as  soon 
as  the  ovarian  influence  is  no  longer  emitted,  i.e.,  when  the  ovaries 


NEW    GROWTHS.  87 

cease  to  perform  their  function.  It  is  then,  as  we  have  already 
shown,  that  the  influence  of  the  sympathetic  system,  which  has  been 
secondary  since  puberty,  begins  again  to  be  the  governing  power. 
When  a  change  of  life  has  been  brought  about  under  healthy  influence, 
the  nutritive  instinct,  as  it  were,  is  gradually  diverted  to  other  points 
of  the  body,  and  manifests  its  decadence  in  any  part  from  which 
diverted  in  the  form  of  fatty  degeneration  of  its  tissues.  Conse- 
quently, nutrition,  when  properly  directed  in  the  uterus,  is  occupied 
no  longer  in  the  formation  of  new  structure,  but  only  in  the  removal 
of  old  material.  It  is  then  possible  that  nutrition  may  be  misdirected 
in  its  attempt  to  remove  the  products  of  some  previous  injury,  and  the 
development  of  a  neoplasm  is  excited,  in  the  nature  of  epithelioma. 
As  atrophy  of  the  uterus  is  brought  about,  the  amount  of  blood  dis- 
tributed to  its  tissues  is  greatly  decreased,  but  that  going  to  the 
mucous  membrane  itself,  which  is  still  to  preserve,  in  some  degree,  its 
function,  is  increased  for  a  time.  The  mucous  follicles,  or  glands, 
gradually  undergo  cystic  degeneration,  and  in  turn  become  atrophied, 
or  they  disappear,  so  that  the  mucous  membrane  is  at  length  greatly 
changed  in  character,  by  comparison  with  its  former  condition. 
Epithelioma  is  a  growth  which  springs  from  the  mucous  membrane, 
and  is  essentially  one  of  perverted  nutrition.  Should  the  progress  of 
this  natural  change  in  the  mucous  membrane  be  retarded  or  obstructed, 
as  we  have  stated,  by  some  injury  which  had  been  but  partially  re- 
paired, it  is  not  difficult  to  understand  that  this  new  growth  might 
arise  as  a  consequence  of  perverted  nutrition.  We  acknowledge  a 
marked  difference  between  the  development  and  progress  of  epithe- 
lioma and  corroding  ulcer.  But  both  conditions,  and  even  cancerous 
infiltration  of  the  pelvic  tissues,  may  have  a  common  local  origin  or 
exciting  cause,  with  distinctive  features  afterwards  determined  by 
some  accidental  surrounding  as  yet  beyond  our  appreciation. 

A  tendency  to  new  growth  in  the  uterine  mucous  membrane  of  those 
who  have  borne  children  increases  as  a  woman  approaches  the  period 
when  the  active  life  of  the  organ  is  to  cease.  Thus  we  find  the  occur- 
rence of  mucous  polypi  more  frequent,  and  the  formation  of  granula- 
tions or  vegetations  more  common  at  this  time  of  life. 

The  nervous  disorders  and  the  reflex  functional  disturbances  of 
women,  in  consequence  of  local  disease  of  the  organs  of  generation, 
present  a  most  important  field  for  investigation.  Our  present  knowl- 
edge enables  us  to  recognize  the  general  relation  of  cause  and  effect, 
but  we  are  yet  unable  to  explain  the  fact  why,  with  apparently  the 
same  local  condition,  a  very  diflerent  train  of  nervous  symptoms  may 


88       CAUSES  OF  DISEASE,  REFLEX  AND  DIRECT. 

result,  not  only  in  different  individuals,  but  in  the  same  person  at  dif- 
ferent times.  Even  a  comparatively  slight  local  cause  of  irritation 
will  frequently  produce  a  marked  disturbance  of  the  brain  or  other 
portion  of  the  nervous  system.  Again,  the  brain  will  react  on  the 
local  condition  to  such  an  extent,  that  the  influence  of  mental  depres- 
sion in  some  individuals  over  the  progress  of  uterine  disease  is  re- 
markable and  quite  evident. 

In  the  female  the  ganglionic  system  is  developed  to  a  greater  extent, 
both  in  the  size  of  the  ganglia  and  in  distribution  of  the  nerves,  than 
in  the  male ;  consequently  her  tenacity  of  life,  and  power  of  long  endu- 
rance, in  resisting  the  efiects  of  disease,  are  greater  than  in  the  other 
sex.  But  this  peculiarity  renders  her  the  more  liable  to  reflex  distur- 
bances from  the  ovarian  or  uterine  disorder. 

It  has  been  shown  that  the  ovarian  influence,  when  normally  exer- 
cised through  the  sympathetic  system  on  nutrition,  is  a  healthy 
stimulus  to  organic  life  ;  but  Avhen  this  stimulus  has  been  impaired, 
or  deflected  as  a  consequence  of  local  disease,  we  have  at  once  some 
reflex  functional  disturbance  elseAvhere. 

There  are  two  great  nerve  centres  which  are  the  recipients,  directly 
or  indirectly,  of  all  nervous  irritation.  The  brain  is  the  centre  of  the 
cerebro-spinal  system,  and  the  solar  plexus,  or  abdominal  brain,  as  it 
has  been  termed,  is  the  centre  of  the  ganglionic  system.  The  spinal 
nerves  enter  the  ganglia  and  convey  back  impressions  to  the  spinal 
system,  and  through  the  latter  they  pass  to  the  brain.  As  long  as 
functional  life  is  properly  regulated,  the  ganglionic  system  is,  as  it 
were,  a  silent  partner  in  the  nervous  circle,  yet  a  busy  one  in  main- 
taining nutrition.  Each  system,  though  complete  in  itself,  is  in  close 
relation  with  the  other,  and  the  two,  like  the  wheels  of  a  Avatch, 
work  harmoniously  together  only  so  long  as  each  performs  its  proper 
function,  and  is  undisturbed  by  extraneous  agencies.  Each  system  is 
in  constant  communication  Avith  the  other,  keeping  up  well-ordered  and 
healthy  action,  and  it  is  only  in  case  of  disorder  that  the  sympathetic 
system  asserts  its  potency  for  evil  by  transmitting  the  morbid  im- 
pression through  the  spinal  nerves  to  the  brain.  A  recognition  of  the 
impression  is  at  once  returned  from  the  brain  to  the  special  ganglion 
of  the  organ  affected,  and  pain  is  expressed  at  the  extremities  of  its 
spinal  nerve. 

In  the  lower'  classes  of  animals  the  ganglionic  system  is  fully  de- 
veloped without  reference  to  the  condition  of  the  brain.  A  morbid 
impression  originating  in  tlic  organs  of  generation  would  be  trans- 
mitted to  the  solar  plexus  and  to  the  spinal  system,  but  without  serious 


NERVOUS    DISORDERS.  89 

reflex  disturbance  to  tlie  brain  itself.  But  in  woman,  as  a  higher  type 
of  development,  the  brain  is  made  to  participate  more  or  less  in  every 
disturbance  in  the  ovario-uterine  circle,  and  she  is  frequently  a  sufferer 
even  when  its  function  is  normally  performed. 

But  when  the  brain  has  been  rendered  morbidly  sensitive  by  faulty 
education,  lack  of  moral  training,  or  by  some  previous  mental  sliock, 
the  whole  force  of  any  disturbance  in  the  organs  of  generation  is 
thrown  directly  on  the  cerebro-spinal  system.  "We  then  have  mani- 
fested certain  forms  of  headache,  unusual  wakefulness,  and  change  in 
disposition.  A  female  will  become  irritable  in  temper,  or  eccentric  ; 
various  degrees  of  hysteria  will  be  developed,  and  every  grade  of 
mental  disturbance  even  to  insanity  itself.  It  is  in  the  woman 
who  has  not  been  trained  to  a  sufficient  moral  restraint,  exercised 
through  her  own  will  or  other  agencies,  that  the  more  marked  forms 
of  hysteria  are  met  with.  A  well-drawn  distinction  should  be  made 
between  hysteria,  which  can  be  held  under  check  by  a  healthy  exercise 
of  the  will,  and  other  nervous  disturbances  Avhich  are  really  beyond 
the  control  of  the  patient. 

When  the  hysterical  development  reaches  a  certain  stage,  and  then 
passes  beyond  the  control  of  the  woman,  we  have  catalepsy,  or  a  con- 
dition Avith  symptoms  resembling  coma,  resulting  from  disease  of  the 
brain  itself.  Under  other  circumstances,  the  morbid  state  of  the  brain, 
in  sympathy  with  the  spinal  nerves,  is  expressed  by  loss  of  motion,  or 
by  simulation  of  diseases  of  the  joints  and  spine.  Again,  reflex  irri- 
tation may  be  manifested  through  the  cerebro-spinal  system  by  dis- 
turbed muscular  action,  in  the  twitching  of  some  special  muscle  by 
chorea,  or  hj  a  first  attack  of  epilepsy.  The  more  marked  the  dis- 
turbance in  the  cerebro-spnial  system,  the  greater  Avill  be  the  proba- 
bility that  the  first  cause  can  be  traced  to  some  error  in  the  mental 
and  physical  training  of  the  child,  by  which  nutrition  has  been  per- 
verted, or  turned  aside  from  its  normal  work.  AVe  find  these  mani- 
festations common  in  the  unfortunate  woman  who  has  had  her  brain 
developed  and  over-taxed  at  the  expense  of  her  organs  of  generation  ; 
in  those  who  give  themselves  over  to  luxury  and  idleness ;  in  the 
victims  of  sentiment  and  romance  ;  and,  in  an  aggravated  form,  in 
those  in  whom  that  sheet  anchor  of  womanhood  is  lacking,  viz.,  a 
devotion  to  duty  and  a  healthy  sense  of  moral  obligation. 

The  woman  who  has  been  trained  to  hold  her  emotions  under  a 
proper  degree  of  discipline,  or  in  whom  they  have  been  held  in  check 
by  a  healthy  occupation  of  body  and  mind,  does  not  necessarily  escape 
every  degree  of  disturbance.     But  when  trouble  comes  the  eftect  is 


90       CAUSES  OF  DISEASE,  REFLEX  AND  DIEECT. 

transient,  and  she  escapes  the  unhealthy  reaction  of  the  disturbed 
brain  on  the  local  disease  of  the  organs  of  generation,  which  is  often 
a  serious  complication.  She  will  be  more  liable  to  suffer  from  some 
reflex  symptom  traceable  directly  to  the  action  of  the  solar  plexus,  or 
to  experience  some  pain  through  the  spinal  nerves.  Such  pain  may 
be  expressed  by  tenderness  on  pressure  at  some  point  over  the  region 
of  the  spine,  or  in  the  organs  of  generation,  about  the  lower  portion 
of  the  abdomen  and  in  the  extremity.  When  the  solar  plexus  is  at 
fault  the  female  suffers  some  degree  of  distress  which  cannot  be  better 
expressed  than  in  the  words  of  an  Irish  woman,  as  "  a  weakness 
entirely,"  which  is  a  sudden  feeling  of  depression  coming  on  without 
any  apparent  cause.  We  find  the  stomach  frequently  sympathizing 
by  reflex  action,  as  evinced  by  nausea,  and  disturbances  in  digestion 
with  dyspeptic  headache.  The  action  of  the  liver  becomes  deranged, 
the  intestines  are  constantly  distended  by  the  accumulation  of  flatus, 
and  occasionally  there  is  diarrhoea.  The  regular  action  of  the  heart 
is  often  disturbed,  and  in  fact  there  is  no  organ  in  the  body  which 
will  not  sympathize  with  an  unhealthy  condition  of  the  female  organs 
of  generation  ;  nor  is  there  any  portion  of  the  body  which  may  not, 
at  some  time,  become  the  seat  of  neuralgia  from  the  same  cause. 

Accidental  Causes  of  Disease. 

Under  this  head,  in  a  general  manner,  have  been  grouped,  1st. 
What  may  be  termed  the  products  of  inflammation,  viz.,  those  result- 
ing from  cellulitis  alone,  or  those  which  follow  the  accumulation  of 
blood  in  a  hematocele  situated  in  the  neighborhood  of  the  uterus, 
and  which,  by  displacing  the  womb,  or  by  obstructing  the  circulation, 
has  led  to  inflammation  of  contiguous  parts  ;  2d.  Injuries  of  the  cervix, 
and  displacements  of  the  uterus  from  violence  ;  3d.  Injuries  to  the 
vagina  and  its  outlet ;  4th.  The  result  of  inflammation  of  the  mucous 
glands  of  the  vagina,  uterus,  or  Fallopian  tubes. 

Of  all  accidental  causes,  inflammation  of  the  cellular  or  connective 
tissue  of  the  pelvis,  and  especially  that  between  the  folds  of  the  broad 
ligaments,  is  the  most  common ;  and  next  in  frequency  may  be  placed 
pelvic  peritonitis  and  hsematocele.  These  conditions  are  of  far  more 
frequent  occurrence  than  is  generally  supposed  by  the  profession. 
Often  they  are  not  recognized  when  existing,  and  their  products,  to 
be  found  long  after  the  original  disease  has  passed  away,  are  almost 
universally  overlooked.  Their  mechanical  effect  is  to  displace  the 
uterus  and  obstruct  its  circulation,  causing  congestive  hypertrophy, 


ACCIDENTAL    CAUSES.  91 

and  often  seriously  interfering  with  the  function  of  the  bladder  and 
rectum,  by  pressure.  After  the  original  condition  has  subsided,  thick- 
ening and  contraction  take  place,  which  will  continue  to  act  as  a 
mechanical  source  of  irritation  to  the  uterus,  and  to  defeat  every 
efi'ort  for  relief  until  the  true  condition  is  fully  appreciated.  For 
instance,  after  an  attack  of  inflammation,  one  of  the  broad  ligaments 
will  become  shortened,  so  that  one  or  both  conditions,  thickening  and 
shortening,  will  be  a  cause  of  irritation.  Either  the  whole  weight  of 
the  uterus  will  be  thrown  on  the  shortened  broad  ligament,  thus  keep- 
ing up  the  cellulitis  on  that  side,  or  the  traction  on  the  opposite  liga- 
ment will  be  sufficient  to  excite  inflammation  in  its  neighborhood.  In 
either  condition,  or  if  both  exist,  no  local  treatment  directed  to  the 
uterus  alone  can  reduce  its  size,  nor  can  it  remove  a  flexure  or  heal 
any  erosion  which  may  result  from  an  attempt  of  the  uterine  vessels 
to  relieve  themselves  of  the  effects  of  an  obstructed  circulation.  The 
first  step  towards  recovery  will  have  been  made  as  soon  as  the  uterus 
has  been  lifted  and  held  in  a  position  in  the  pelvis  in  which  this  trac- 
tion and  the  obstruction  to  the  circulation  will  be  relieved.  The 
effect  also,  on  the  bladder  and  rectum,  will  be  to  remove  the  reflex 
irritation  they  send  to  the  uterus,  a  source  often  overlooked  in  the 
confusion  as  to  cause  and  effect.  Later  in  this  work,  when  treating 
of  displacements,  this  important  subject  will  be  carefully  considered. 

Inflammation  of  the  ovarian  structure,  in  proportion  to  its  extent, 
will  act  as  a  source  of  reflex  irritation  to  the  uterus,  causing  conges- 
tive hypertrophy,  by  obstructing  its  circulation,  or  inducing  its  retro- 
version. 

Sloughing  from  continued  pressure  of  the  child's  head  on  the 
vaginal  walls  during  labor,  resulting  in  fistul?e,  or  loss  of  tissue  with 
subsequent  contraction,  will  often  displace  the  uterus,  interfere  with 
the  circulation,  and  cause  much  irritation  to  the  bladder  and  rectum. 
The  same  cause  and  injury  to  the  uterus  often  result  in  atrophy  of 
the  organ  with  permanent  cessation  of  menstruation,  even  in  early 
womanhood. 

Inversion  of  the  uterus  will  impair  the  general  condition  by  the 
continued  loss  of  blood,  and  by  the  drain  on  the  system  from  the 
excessive  leucorrhoea,  but  this  condition  seldom  occurs  directly  from 
violence. 

Violence,  as  the  result  of  rapid  labor,  or  of  labor  prolonged  until 
the  parts  have  lost  their  natural  elasticity,  and  instrumental  delivery, 
acting  mechanically,  afterwards,  as  a  source  of  irritation,  may  be 
enumerated  as  causes  of  lacerations  of  the  cervix  and  of  the  peri- 


92       CAUSES  OF  DISEASE,  REFLEX  AND  DIRECT. 

neum,  partially  or  through  the  sjohincter  ani.  It  will  be  seen  here- 
after that  laceration  of  the  cervix  becomes  a  most  frequent  cause  of 
uterine  disease,  arresting  involution,  and  afterwards  mechanically, 
through  the  irritation  established  by  the  separation  of  the  flaps. 
Hypertrophy  of  the  uterus  is  kept  up  and  increased  by  this  source 
of  irritation,  and  an  intractable  form  of  erosion  is  produced  with  an 
increased  menstrual  flow  and  an  exhausting  leucorrhoea  in  the  inter- 
vals. As  a  consequence  of  laceration  of  the  perineum,  we  have  a 
prolapse  of  the  vaginal  wall  from  want  of  proper  support ;  the  uterus 
then  becomes  retroverted,  and,  in  consequence  of  the  obstruction  to 
the  circulation  from  its  malposition,  still  further  increases  in  size. 

Direct  violence,  as  from  a  fall,  will  frequently  cause  retroversion, 
especially  if  it  should  happen  that  the  bladder  is  filled  with  urine  at 
the  time  of  the  accident.  This  displacement  of  the  uterus,  in  propor- 
tion to  the  degree,  is  always  attended  by  some  obstruction  to  the  cir- 
culation, which  increases  the  size  of  the  organ,  and,  if  cellulitis  follows, 
in  consequence  of  the  injury,  a  flexure  is  frequently  a  result. 

The  most  frequent  effect  of  the  formation  of  cicatricial  tissue  about 
the  cervix,  after  inflammation  or  induration  following  the  continued 
use  of  caustics  or  the  nitrate  of  silver,  is  general  nervous  irritability, 
and  neuralgia  in  different  parts  of  the  body.  It  is  suflicient  at  present 
to  direct  attention  to  the  fact  that  the  cervix  is  covered  Avith  erectile 
tissue,  and  is  therefore  largely  supplied  with  bloodvessels  which  are 
inclosed,  as  it  were,  in  a  network  of  nerves  from  the  sympathetic 
system.  An  appreciation  of  its  structure  will  fully  explain  the  reflex 
irritation  from  which  women  so  frequently  suffer  in  connection  with 
injuries  and  disease  of  the  cervix. 

Inflammation  of  the  mucous  membrane  of  the  vagina,  uterine  canal, 
and  Fallopian  tubes,  is  caused  by  exposure  to  cold,  by  irritating  dis- 
charges, violence,  and  specific  poisons.  From  some  unknown  cause  or 
connection  vaginitis  and  inflammation  of  the  membrane  of  the  uterine 
canal,  without  involving  the  deeper  tissues,  will  sometimes,  as  has  oc- 
curred under  my  observation,  suddenly  cease  as  by  metastasis,  and 
be  followed  by  an  attack  of  cellulitis  or  peritonitis.  Simple  vaginitis, 
as  a  catarrhal  affection  or  when  caused  by  irritative  uterine  discharges, 
is  of  little  consequence  beyond  the  temporary  disturbance.  When  the 
inflammation,  however,  has  been  produced  by  gonorrhoea,  it  is  apt  to 
involve  the  mucous  membrane  of  the  urethra,  and  may  even  cause 
cystitis,  by  an  extension  of  the  inflammation  to  the  bladder. 

According  to  the  observations  of  Dr.  Noeggerath  of  this  city,  the 
secretions  from  the  urethra  of  a  man  who  has  a  stricture,  the  result 


DISEASE    OF    MUCOUS    FOLLICLES.  93 

of  gonorrhoea,  are  of  a  sufficiently  irritativ^e  character  to  establish  in- 
flammation in  the  genital  tract  of  the  -wife,  its  favorite  locality  being 
in  the  Fallopian  tubes.  As  a  result  of  this  inflammation  there  will 
be  blocking  up  and  narrowing  of  these  tubes,  and  this  he  regards  as  a 
common  cause  of  sterility.  The  condition  described  I  have  frequently 
seen  after  death,  but  without  any  knowledge  as  to  the  cause,  while  I 
have  never  met  with  an  instance  presenting  any  symptoms  by  which 
I  could  recognize  its  existence  during  life. 

Cystic  disease  of  the  mucous  follicles  is  a  condition  brought  about 
by  long-continued  inflammation  of  the  cervix,  and  by  the  frequent  use 
of  nitrate  of  silver  and  other  caustics.  As  an  efi"ect  of  inflammation, 
the  submucous  tissue  is  rendered  dense  and  changed  in  character  so 
that  the  supply  of  blood  to  the  mucous  glands  is,  in  a  great  degree, 
cut  ofi".  Their  outlets  become  closed  and  the  glands  are  destroyed 
by  undergoing  cystic  degeneration.  When  a  number  become  involved 
the  pressure  exerted  by  them  is  often  sufficient  to  destroy  other  glands 
in  the  neighborhood  which  may  not  have  yet  taken  on  the  same  condi- 
tion. When  this  pressure  is  not  relieved  by  puncture,  the  diseased 
condition  is  likely  to  become  extensive  ;  the  cysts  gradually  rupture 
from  over-distension,  their  cavities  contract,  and  eventually  atrophy  of 
the  uterus  follows  the  previous  hypertrophy  of  the  cervix.  Atrophy  of 
the  uterus  from  this  cause  may  take  place  early  in  life  as  the  result  of 
laceration  of  the  cervix,  or  from  any  other  cause  by  which  inflamma- 
tion is  established,  and  I  have  frequently  seen  the  cessation  of  men- 
struation, after  this  change,  followed  by  the  rapid  development  of 
phthisis. 


94  PRINCIPLES    OF    GENERAL    TREATMENT. 


CHAPTER    VI. 

PRINCIPLES  OF  GENERAL  TREATMENT. 

Confidence  of  the  patient  essential  to  success — Influence  of  tlie  mind  over  disease 
— Ansemia — Method  of  improving  digestion  and  nutrition — Influence  of  sun- 
light— Influence  of  diet,  etc.  :  coffee,  stimulants,  anodynes — Habitual  invalids — 
Dress — Hours  for  meals,  etc. — Importance  of  details. 

There  are  certain  general  principles  applicable  in  the  treatment  of 
all  forms  of  uterine  disease  without  reference  to  special  treatment. 
All  forms  of  local  disease  of  long  standing  are  closely  connected  with 
faulty  nutrition.  Commonly  there  exists  some  impairment  of  the 
general  health  manifested  by  functional  derangement  with  anaemia, 
and  the  local  disease  is  kept  up  by  a  loss  of  tone  in  the  pelvic  vessels. 
Our  means  of  treatment  are  to  be  directed  chiefly  with  the  view  of 
improving  nutrition,  and  giving  tone  to  these  bloodvessels  in  the 
pelvis.  It  is  necessary  for  success  that  the  patient  should  receive 
careful  general  as  well  as  local  treatment.  Both  are  essential,  and 
the  physician  who  neglects  either  will  be  disappointed  in  his  results. 

There  can  be  no  restoration  to  health  in  either  the  local  or  general 
condition,  so  long  as  anaemia  exists,  since  the  blood  has  lost  those 
elements  by  which  organic  life  is  properly  stimulated.  In  a  case  of 
long  standing  we  will  scarcely  find  an  organ  in  the  body  which  is  not 
suifering  from  functional  derangement.  The  connection  of  one  func- 
tion with  another,  as  we  have  seen,  is  so  intimate  in  the  organic  circle 
of  nutrition  that  the  derangement  of  any  one  soon  jeopardizes  the  in- 
tegrity of  the  whole ,  The  result  will  be  enfeebled  digestion,  a  slug- 
gish portal  circulation,  and  imperfect  respiration.  The  blood  is  no 
longer  oxygenized  properly,  and  it  is  returned  to  the  general  circu- 
lation in  a  condition  not  unlike  that  of  a  cold-blooded  animal.  The 
kidneys  are  over-worked,  and  the  skin  is  inactive  ;  repair,  to  a  cer- 
tain extent,  has  ceased,  and  general  Avaste  is  the  rule.  In  addition, 
we  often  have  combined  in  the  same  subject,  the  pernicious  effects 
following  the  habitual  use  and  abuse  of  alcohol  in  some  form,  ano- 
dynes, and  coffee. 

The  first  step  in  the  treatment  of  every  case  is,  if  possible,  to  gain 
the  patient's  entire  confidence.     As  the  mind  has  so  much  influence 


ANODYNES    AND    STIMULANTS.  95 

over  the  body,  she  must  be  impressed  with  the  certainty  of  her 
recovery  if  the  physician  can  conscientiously  anticipate  such  a  result. 
But  he  should  never  commit  himself  by  stating  the  time  necessary  for 
the  patient  to  regain  her  health,  since  this  must  vary  in  each  indi- 
vidual. The  physician  should  never  allow  himself  to  be  placed  in  a 
position  where  his  truthfulness  may  be  questioned  by  the  patient. 
She  will  never  forgive  any  attempt  to  deceive  her  by  holding  out 
false  hopes,  and  when  once  her  confidence  has  been  shaken,  but  little 
further  progress  will  be  made  in  the  treatment  of  her  case.  The 
patient  is  to  be  taught  to  keep  her  nervous  manifestations  under 
strict  control,  for  it  is  a  healthy  discipline,  and  as  she  is  to  be  en- 
couraged and  aided  by  her  physician,  this  influence  cannot  be  exer- 
cised if  their  relation  be  on  too  intimate  a  footing.  He  should  be 
kind  and  forbearing,  but  just  to  himself  in  this  respect,  without  a 
show  of  sympathy. 

Whenever  a  patient  has  become  addicted  to  the  use  of  stimulants, 
anodynes,  or  coffee,  an  effort  must  be  made  at  once,  without  a  com- 
promise, to  break  up  the  dependence  upon  either  of  these  insidious 
poisons  to  the  nervous  system.  Their  indiscriminate  use  having,  in 
the  beginning,  aided  not  a  little  in  bringing  about  the  general  wreck, 
a  continuance  would  but  defeat  the  best  devised  eiforts  for  a  restora- 
tion. I  have  rarely  met  with  an  instance  where  the  patient  was  so 
far  reduced  that  this  plan  could  not  be  carried  out,  and  it  is  the  one 
attended  in  the  end  with  the  least  suffering.  In  private  practice,  at 
the  house  of  a  patient,  this  may  be  difficult  to  carry  out.  But  in  my 
private  hospital,  the  case  would  be  kept  under  a  strict  watch,  since  the 
most  truthful  person  cannot  be  trusted  when  going  through  the  ordeal 
of  a  recovery  from  the  influence  of  either  alcohol  or  opium.  The 
profession  has,  indeed,  much  to  answer  for,  since  many  a  confirmed 
invalid  has  been  brought  to  this  condition  from  the  continued  use  of 
stimulants,  but  more  especially  anodynes,  ordered  by  the  medical  at- 
tendant. Rarely,  indeed,  is  there  a  necessity  for  the  repeated  use  of 
anodynes,  except  during  some  attack  of  inflammation,  for  some  special 
purpose  after  a  surgical  operation,  or  to  one  suffering  from  the  ad- 
vanced stages  of  malignant  disease.  It  is  an  easy  method  of  practice, 
but  an  unwarrantable  one,  to  inject  a  little  morphine  under  the  skin, 
or  to  administer  the  hydrate  of  chloral,  to  save  annoyance  or  the 
proper  investigation  for  every  real  or  imaginary  pain  of  a  nervous 
woman.  It  has  been  my  misfortune  to  see  so  much  of  the  evil  effects 
of  this  easily  acquired  habit,  far  more  difficult  to  overcome  than  the 
original  disease,  that,  for  years  past,  I  have  abandoned  the  use  of 


96  PRINCIPLES    OF    GENERAL    TREATMENT. 

the  hypodermic  syringe.  I  rarely  give  opium  in  any  form  by  the 
mouth,  and  only  under  the  above  stated  conditions  by  enema. 

This  mode  of  administration  does  not  disturb  the  digestion  so  much  ; 
a  smaller  dose,  comparatively,  will  answer  for  a  longer  time,  without 
necessitating  an  increase  in  quantity,  while  the  method  is  one  the 
least  likely  to  be  resorted  to,  except  from  necessity.  In  private 
practice  the  case  becomes  almost  a  hopeless  one  from  the  hour  that 
the  patient  becomes  dependent  upon  the  use  of  an  anodyne.  There 
can  be  no  improvement  afterwards  in  the  powers  of  nutrition,  and  the 
nervous  symptoms  are  all  increased,  so  as  to  mask  the  true  condition. 
The  woman  becomes  a  sufferer  from  opium  neuralgia,  or,  rather,  its 
habitual  use  brings  about  such  an  impairment  or  prostration  of  all 
her  vital  forces,  that  the  power  of  endurance  is  lost,  and  every  un- 
comfortable feeling  becomes  intensified  into  pain.  The  only  hope  for 
the  future  is  to  cut  oif  the  supply,  as  I  have  stated,  and  the  physician 
in  private  practice  is  fortunate,  who  can  make  the  attempt  with  the 
support  of  her  friends,  in  carrying  out  a  course  attended  apparently 
with  so  much  suffering  and  cruelty  to  the  patient.  It  will  be  neces- 
sary to  resort  temporarily  to  the  judicious  use  of  the  bromide  of 
potassium,  to  give  more  nourishment,  and  to  adopt  means  for  improving 
the  general  condition. 

Digestion  can  be  aided  at  first  but  little  by  the  use  of  medicines, 
and  our  chief  dependence  will  be  simple  but  nutritious  food,  small  in 
bulk,  and  administered  frequently  and  with  regularity.  As  soon  as 
possible,  attention  must  be  directed  to  bringing  about  of  a  healthy 
action  of  the  skin,  by  the  use  of  hot-air  baths,  general  friction,  and 
frequent  exposure  of  the  body  to  the  direct  action  of  sunlight. 

Facilities  for  taking  a  Turkish  bath  are  to  be  found  in  most  of  the 
cities,  and  in  the  country  some  substitute  can  be  resorted  to.  The 
use  of  hot  air  answers  better  for  a  class  of  cases  suffering  from 
anaemia  than  the  steam  or  Russian  bath,  which  is  best  fitted  for 
persons  more  robust.  Exposure  to  the  action  of  the  hot  air  should 
not  be  prolonged,  at  first,  beyond  ten  or  fifteen  minutes,  which  is 
generally  long  enough  to  cause  the  skin  to  perspire  freely.  The 
patient  is  to  be  then  sponged  off  with  water  as  cold  as  can  be  borne 
Avithout  producing  a  shock,  thoroughly  dried,  and  well  rubbed  from 
head  to  foot.  She  should  afterwards  get  to  bed  as  soon  as  possible, 
take  some  beef-tea  or  other  nourishment,  and  rest  an  hour  or  two. 

A  hot-air  bath  can  be  extemporized  by  the  patient  lying  at  full 
length  on  a  cane-bottomed  sofa,  or  several  chairs,  with  a  number  of 
spirit  lamps  placed  beneath,  on  as  many  large  plates,  Avliilc  the  per- 


THE    IIOT-ATR    BATH.  97 

son  and  chairs  are  covered  by  blankets.  I  have  often  resorted  to 
this  phin  when  a  patient  couhl  not  be  carried  a  distance  to  the  public 
bath,  and  it  answers  very  well.  I  direct  two  large  blankets  to  be 
spread  out  on  the  floor,  the  row  of  chairs  to  be  placed  in  the  centre, 
with  the  spirit  lamps  under  them.  I  first  have  the  lamps  lighted, 
and  the  ends  of  the  blankets  turned  up  over  the  chairs,  until  the  air 
has  been  heated.  It  is,  of  course,  necessary  for  the  temperature  of 
the  room  to  be  properly  regulated  beforehand,  that  the  patient  may  be 
in  no  danger  of  contracting  cold  from  exposure.  She  is  then  to  be 
placed  nude  and  at  full  length  on  these  chairs  or  sofa,  in  a  comfort- 
able position,  and  provided  with  a  pillow.  The  ends  of  the  blankets 
placed  under  the  chairs  are  to  be  turned  up  over  her  and  covered 
with  a  third  blanket,  leaving  only  her  face  uncovered,  so  that  she  lies 
directly  on  the  perforated  cane  bottom  with  her  body  exposed  to  the 
heated  air  from  below.  At  first,  it  requires  the  exercise  of  a  little 
faith  on  the  part  of  the  patient,  as  the  position  is  not  unlike  being  on 
a  gridiron  over  a  fire,  but  in  fact  the  body  is  at  too  great  a  distance 
to  be  sensible  of  the  flames  below,  and,  if  the  lamps  are  properly 
placed,  there  will  be  no  danger  of  setting  fire  to  the  blankets.  As 
soon  as  the  skin  begins  to  act  freely,  the  limbs,  and  then  the  body,  in 
turn,  can  be  sponged  off,  well  dried  and  rubbed.  This  can  be  done 
without  exposure  of  more  than  a  portion  of  the  body  at  a  time,  and 
each  part  can  be  covered  with  a  dry  blanket  until  the  patient  has 
cooled  sufficiently  to  be  placed  in  bed  or  to  have  her  clothing  put  on. 
When  she  is  strong  enough  to  help  herself,  she  may  envelop  her  body 
in  the  top  blanket,  and  step  directly  into  a  full-length  bath,  filled  with 
water  of  a  comfortable  temperature,  after  which  she  may  be  dried 
and  well  rubbed.  This  bath  may  be  repeated  two  or  three  times  a 
week,  or,  when  the  patient  is  strong  enough,  it  may  be  taken  daily. 
AVith  any  improvement  in  the  condition  of  the  skin,  and  in  a  patient 
whose  limbs  are  always  cold  to  the  knees,  there  wall  follow  a  relief 
through  the  circulation,  to  the  overtaxed  kidneys,  the  portal  system, 
and,  indirectly,  digestion  Avill  be  aided. 

We  may  learn  much  from  the  practice  of  the  hydropathists,  who 
often  succeed  in  restoring  the  general  health  and  improving  the  local 
condition,  after  others  have  failed  to  accomplish  as  much  by  the  use 
of  tonics  and  other  remedies,  when  the  patient  has  been  unable  to 
assimilate  her  food  properly.  Their  practice  is  to  envelop,  or  "  pack," 
the  body  in  a  wet  sheet,  using  warm  Avater,  and  then  to  cover  the  body 
with  blankets  until  a  free  action  of  the  skin  is  established.  Then  a 
7 


98  PRINCIPLES    OF    GENERAL    TREATMENT. 

bath  follows,  with  friction  afterwards,  which  is  an  excellent  method  of 
accomplishing  the  purpose,  when  the  patient  is  able  to  take  exercise. 
The  action  of  sunlight  is  beneficial  in  relieving  the  ansemia,  by 
creating  a  tolerance  of  the  stomach  for  the  preparations  of  iron. 
The  use  of  iron,  in  any  form,  and  sunlight  must  go  together,  for, 
without  the  aid  of  the  latter,  ferruginous  preparations  are  not  properly 
absorbed  by  the  stomach,  and  must  act  as  irritants.  It  is  a  most 
difficult  matter  for  women  to  carry  out  this  important  practice,  it 
being  essential  that  the  whole  body  should  be  directly  exposed  to  the 
rays  of  the  sun.  Those  who  need  it  the  most  are  generally  too  feeble 
to  be  sent  to  establishments  in  the  city  fitted  up  for  affording  the 
necessary  facilities,  and,  therefore,  for  a  time  at  least,  the  invalid 
must  utilize  the  sunlight  in  her  own  room.  The  best  period  of  the 
day  is  an  hour  or  two  before  noon.  The  patient  can  be  placed  in 
front  of  a  window  on  a  low  lounge  or  sofa,  covered  with  a  blanket,  so 
that  she  may  protect  herself  from  cold  by  covering  the  part  of  her 
body  which  at  the  time  is  not  exposed  to  the  sunlight.  Unless  the 
Aveather  is  very  mild,  and  the  room  warm  enough,  it  is  safer  that  she 
should  keep  on  her  stockings,  and,  if  solicitous  for  her  complexion,  her 
face  can  be  protected  with  a  veil,  and  her  hands  covered  by  gloves. 
If  in  cold  weather,  and  the  Avindow  should  be  near  enough  to  the  fire, 
she  can  lie  on  the  floor  with  several  blankets  and  a  mattress  under 
her,  and  with  a  screen  she  can  be  protected  from  drafts  and  from 
observation.  So  long  as  she  is  not  likely  to  take  cold  from  exposure, 
or  to  suffer  from  fatigue,  she  may  remain  lying  in  the  sun  for  hours, 
and  Avithout  exposing  her  whole  body  at  any  one  time  she  may,  in 
turn,  bring  every  portion  into  the  light.  This  mode  of  treatment  is 
most  satisfactory  in  its  results,  and  would  be  perfect  if  Ave  could  at 
the  same  time  combine  Avith  it  the  benefit  of  fresh  air.  For  all  the 
annoyances  which  must  necessarily  attend  this  practice,  the  patient 
Avill  be  fully  compensated  ;  but  it  must  be  persevered  in  for  Aveeks, 
and  sometimes  for  months.  During  the  time  of  menstruation  the 
patient  may  lie  in  the  sun,  Avith  her  clothing  on,  but  should  not  run 
the  risk  of  exposing  her  body  to  the  cold.  I  have  knoAvn  tAvo  instances 
in  Avhich  the  period  Avas  suddenly  arrested  by  this  exposure,  and  Avhile 
the  effect  was  likely  due  to  cold,  it  is  possible  that  the  sun  may  have 
sufficiently  disturbed  the  circulation  and  brought  about  the  arrest,  by 
diverting  an  increased  quantity  of  blood  to  the  capillaries  of  the  skin. 
As  soon  as  the  angemia  is  lessened  to  some  extent,  and  the  condition 
of  the  blood  improved,  the  capillary  action  Avill  become  more  vigorous, 
and  the  poAver  of  both  assimilation  and  elimination  must  increase.    We 


PURGATIVES.  99 

can  then  do  more  hj  medicinal  means  to  assist  digestion,  and  the  use  of 
tonics  and  preparations  of  iron  may  be  resumed. 

There  Avill  be  presented  such  a  variety  of  symptoms  due  to  derange- 
ment of  the  digestive  organs,  that  the  physician  will  have  to  exercise 
his  judgment  in  each  individual  instance.  It  is  a  well-established  fact 
that,  so  long  as  the  tongue  remains  coated,  and  the  bowels  overloaded, 
little  or  nothing  can  be  accomplished  by  the  use  of  tonics.  I  am  often 
impressed  with  the  conviction  that  there  is  no  error  so  frequently  made 
in  the  treatment  of  these  diseases  as  the  neglect  of  brisk  purgatives 
from  time  to  time,  in  the  form  of  some  mercurial.  Even  those  who 
are  apparently  in  a  most  debilitated  condition  are  benefited  by  such 
treatment,  and,  although  the  prostration,  for  the  time,  may  be  increased, 
it  is  more  apparent  than  real,  since  reaction  is  generally  prompt.  It  is 
a  marvel  that  blood-poisoning  is  not  the  rule  in  these  cases,  when  we 
consider  the  almost  incredible  accumulation  which  often  takes  place  in 
the  intestinal  tract,  and  the  vitiated  character  of  the  secretions.  This 
degree  of  tolerance  is  a  favorable  feature  in  some  respects,  but  until 
the  accumulation  has  been  removed,  and  the  character  of  the  secretions 
changed,  there  can  be  no  improvement  in  the  appetite.  All  means 
adopted  to  stimulate  digestion — this  condition  remaining — must  fail, 
and  only  add  to  the  disturbance.  By  emptying  the  bowels  thoroughly, 
and  relieving  the  portal  system,  we  accomplish  much  from  the  o-ood 
effect  on  digestion,  and,  at  the  same  time,  remove  the  chief  obstacle 
to  the  proper  return  of  the  venous  blood  from  the  pelvis,  through  the 
liver,  into  the  general  circulation. 

Unless  there  exists  some  contra-indication,  I  generally  adopt  the 
following  plan,  as  one  of  the  first  steps  in  the  treatment  of  those  who 
have  long  suffered  as  chronic  invalids. 

I  direct  half  an  ounce  of  inspissated  ox-gall  to  be  dissolved  in  a 
basin  of  warm  water,  and  thrown  into  the  colon  by  means  of  a 
Davidson  syringe,  while  the  patient  is  on  her  knees  and  elbows. 
The  greater  portion  of  this  quantity  of  water  can  be  introduced  in 
this  position  if  it  be  done  slowly.  By  making  firm  pressure  against 
the  anus  with  a  folded  towel,  the  patient  can  be  greatly  aided  in  re- 
taining the  injection  long  enough  for  the  ox-gall  to  act  as  a  solvent. 
The  patient,  in  all  probability,  will  be  much  exhausted,  neverthe- 
less, after  twelve  hours,  eight  or  ten  grains  of  the  mild  chloride  of 
mercury,  one  scruple  of  the  bicarbonate  of  soda,  and  half  a  grain  of 
ipecacuanha  may  be  administered  at  bedtime  by  the  mouth.  The 
soda  will  have  the  effect  of  increasing  the  purgative  action  of  the 


IGO  PRINCIPLES    OF    GENERAL    TREATMENT. 

mercurial  far  beyond  what  would  result  from  its  use  alone.  Its  ac- 
tion will  not  be  excessive,  nor  will  an  additional  purgative  be  required. 
It  will  be  found  that  more  food  can  now  be  borne,  and  digestion  may 
be  aided  by  the  use  of  some  bitter  tonic  infusion.  After  a  few  days, 
should  the  tongue  continue  to  be  coated,  it  is  a  good  practice  to  ad- 
minister a  scruple  or  more  of  ipecacuanha,  and  after  the  stomach  has 
become  settled,  to  repeat  the  dose  of  calomel  and  soda. 

The  course  I  have  pointed  out  is  apparently  a  harsh  one  for  a  class 
of  patients  generally  suffering  from  debility,  yet  it  is  almost  always 
borne  well,  and  in  the  end  fully  compensates  for  the  temporary  dis- 
turbance.    Beyond  question  these   cases  are  prostrated,  and  suffer 
from  the   condition  which  I  have   described,  and  cannot  be  relieved 
by  mild  means ;  but  the  impression  made  by  the  treatment  above 
suggested  is,  as  a  new  sensation,  beneficial.      Afterwards  it  may 
be  necessary  again  to  resort  to  the  same  purgative,  or  a  blue  pill, 
but  with  a  little  care  it  will  be   easy  to  regulate  the  bowels,  and 
any  tonic  treatment  will  be  followed  by  improvement  in  the  general 
condition.     Many  of  the  mineral  waters,  with  or  without  iron,  may 
be  found  serviceable  when  taken  before  breakfast,  for  the  purpose 
of  acting  on  the  bowels.     The  preparation  long  in  use,  and  known 
as  the  Rigby  mixture,  answers  well  Avith  many  cases.     It  consists  of 
an  ounce  or  more  of  the  sulphate   of  magnesia,   dissolved  in  some 
seven  ounces  of  water.     The  salt  is  converted  into  a  bisulphate,  and 
rendered  more  active  by  the  addition  of   a    drachm  of  dilute  sul- 
phuric acid.     An  ounce  of  the   syrup  of  orange  peel,  with  fifteen 
grains  of  the  sulphate  of  iron,  if  needed,  may  be  added,  and  from 
one  to  two  tablespoonfuls  in  a  little  water  is  to  be  taken  early  in  the 
morning.     This  combination  is  an  excellent  one,  as  it  does  not  consti- 
pate after  using  it  for  any  length  of  time,  but  may  be  from  time  to 
time  left  off  and  resumed  again  when  needed.     As  with  all  saline 
purgatives,  its  action  is  rendered  more  prompt  by  some  warm  fluid,  as 
a  cup  of  tea,  taken  into  the  stomach  shortly  after  the  medicine  has 
been  administered.    When  the  patient  is  unable  to  exercise,  and  there 
is  a  tendency  to  fecal   accumulation,  five  grains  of  inspissated  ox- 
gall, made  into  a  pill,  may  be  gi-\^en  three  times  a  day,  with  a  small 
dose  of  rhubarb  and  soda  every  other  night.     The  habit  of  regularity 
must  be  established,  and  if  necessary,  the  use  of  a  small  enema  of 
tepid  water  can  be  employed  to  bring  about  the  action  at  a  regular 
time.     It  is  often  necessary  to  combine  strychnia,  or  some  other  pre- 
paration of  nux  vomica,  with  the  various  remedies  used  to  regulate 
the  bowels.     This  is  done  with  the  vicAv  of  exciting  and  giving  tone  to 


PREPARATIONS    OF    IRON.  101 

the  muscular  tissue  of  the  intestines  which  has  become  gradually  over- 
stretched, and,  considering  its  -well-known  property  of  increasing  the 
action  of  other  medicines,  a  smaller  dose  can  be  used  than  would  be 
necessary  without  it.  In  combination  with  other  agents,  small  doses 
of  ipecacuanha  are  often  beneficial  as  a  promotor  of  digestion.  From 
a  quarter  to  half  a  grain,  three  times  a  day,  increases  peristaltic  ac- 
tion, and  improves  the  character  of  the  secretions.  It  either  has  a 
tonic  effect  of  itself,  or  it  acts  indirectly  as  a  tonic,  by  increasing  the 
action  of  that  class  of  remedies. 

It  is  generally  a  matter  of  experiment  as  to  the  preparation  of  iron 
best  suited  to  the  individual  case,  and  more  benefit  is  derived  by  a 
frequent  change  than  from  the  long-continued  use  of  any  one  prepa- 
ration. Those  in  combination  with  the  vegetable  acids,  as  the  citrate 
and  tartrate  of  iron,  are  always  borne  if  iron  in  any  form  can  be 
taken.  The  tartrate  of  iron  and  potassa,  from  its  tendency  to  relax 
the  bowels,  or  rather  not  to  constipate,  is  also  an  excellent  preparation. 
When  a  change  becomes  necessary,  the  mistura  ferri  composita  should 
be  tried,  than  Avhich  we  have  few  preparations  of  iron  better  fitted  for 
giving  tone  to  the  organs  of  digestion.  As  soon  as  the  stomach  be- 
comes tolerant  to  other  preparations  of  iron,  I  generally  resort  to  that 
time-honored  one,  the  tincture  of  the  perchloride,  which,  after  all,  is 
probably  the  most  reliable  preparation  in  the  Pharmacopoeia.  After 
it  has  been  made  several  years,  and  is  in  a  condition  in  which  it  is 
usually  thrown  out  by  the  druggist,  it  causes  less  headache,  and  is 
best  tolerated  by  the  stomach,  owing  to  a  certain  amount  of  free  acid 
which  it  then  contains.  It  can  be  taken  with  a  little  water,  in  drachm 
doses,  when  ten  drops  of  the  recent  preparation  would  not  be  so  well 
tolerated ;  and,  although  the  effect  on  the  teeth  is  objectionable,  this 
can  be  avoided  by  carefully  using  a  glass  tube,  and  afterwards  the 
tooth-brush.  There  are  various  preparations  of  iron,  recently  manu- 
factured, which  can  be  given  in  an  effervescent  form — one  always 
most  acceptable  where  the  digestive  powers  are  not  good. 

The  same  rules  of  diet  as  would  be  applicable  in  general  practice 
are  to  be  followed,  and  the  individual  peculiarities  of  each  case 
must  determine  the  treatment. 

Before  a  patient  is  able  to  take  a  cejtain  amount  of  exercise,  the 
food  must  necessarily  be  more  concentrated,  be  given  in  less  quantity 
and  often,  in  the  same  manner  as  would  be  directed  for  a  convalescent. 

Until  the  patient  becomes  tired  of  its  use,  an  important  article  of 
diet  is  freshly-made  concentrated  beef-tea.  Raw  beef  thoroughly 
rubbed  up  in  a   mortar,  then  seasoned  and  made  into  a  sandwich, 


102  PRINCIPLES    OF    GENERAL    TREATMENT. 

Avill  be  of  service,  until  the  tender-loin  of  a  beef-steak  can  be 
digested.  Milk  and  cream  should  be  given  in  such  quantities  as  the 
patient  may  be  able  to  digest,  and  if  a  liberal  amount  of  salt  be  added 
to  the  milk,  it  will  be  less  constipating,  and  will  be  found  to  agree  with 
a  larger  number  of  persons. 

One  great  object  in  the  use  of  concentrated  food  is  to  obviate  any 
accumulation  in  the  bowels,  since  the  great  difficulty  generally  is  to 
keep  the  bowels  regular  while  the  patient  is  unable  to  take  exercise. 
Purgatives  cannot  be  employed  all  the  time,  and  we  have  already  noted 
the  necessity  of  relieving  the  circulation  in  the  pelvis  by  keeping  the 
bowels  free  from  accumulations. 

It  is  advisable  to  administer  cod-liver  oil  as  soon  as  it  can  be  borne 
without  disturbance,  and  if  taken  towards  the  completion  of  digestion, 
instead  of  just  after  a  meal,  it  will  remain  so  short  a  time  in  the 
stomach  that  it  is  not  likely  to  disagree.  An  excellent  substitute  and 
one  often  better  tolerated,  is  the  fat  of  pork  properly  prepared.  I 
direct  a  thick  portion  of  a  rib  piece,  free  from  lean,  to  be  selected  and 
allowed  to  remain  in  soak  for  thirty-six  hours  before  being  boiled,  the 
Avater  being  frequently  changed  to  get  rid  of  the  salt.  It  should  be 
boiled  slowly,  and  thoroughly  cooked,  and  while  boiling,  the  water 
must  be  changed  several  times  by  pouring  it  off,  and  fresh  water  nearly 
boiling  substituted.  It  is  to  be  eaten  cold  in  the  form  of  a  sandwich 
made  from  stale  bread,  and  both  should  be  cut  as  thin  as  possible. 
It  is  very  nutritious,  but  it  should  only  be  given  in  small  quantities  until 
a  taste  for  it  has  been  acquired.  It  is  the  most  concentrated  form  in 
which  food  can  be  taken  in  the  same  bulk,  and  I  have  frequently  seen 
it  retained  when  the  stomach  Avas  so  irritable  that  other  substances 
would  be  rejected.  For  this  condition  of  the  stomach  it  may  be  rubbed 
up  thoroughly  in  a  porcelain  mortar  and  then  given  in  minute  quanti- 
ties at  a  time.  It  is  made  more  palatable  by  the  addition  of  a  little 
table  salt,  and  this  will  be  well  tolerated,  while  the  salt  used  for 
preserving  the  meat  having  become  rancid,  if  not  soaked  out,  Avill  pro- 
duce disturbance  in  even  a  healthy  stomach.  I  some  years  ago  saved 
the  lives  of  two  of  ray  children,  who  on  different  occasions  Avere  suffer- 
ing from  cholera  infantum,  by  feeding  them  entirely  on  the  fat  of  pork 
prepared  in  the  way  I  have  described,  and,  Avhile  nothing  else  would 
be  retained  on  their  stomachs,  not  only  was  it  retained,  but  it  also  had 
a  beneficial  effect  on  the  diarrhoea. 

This  would  prove  a  most  useful  article  for  the  sick  and  dyspeptic 
if  we  called  it  by  another  name  ;  and  as  the  prejudice  against  it  is 


STIiMULANTS    AND    ANODYNES.  103 

naturally  great,  the  patient  had  better  become  accustomed  to  its  use 
before  learning  any  particulars  as  to  its  character. 

I  have  frequently  found  coffee,  even  when  taken  weak,  to  exert 
a  very  deleterious  effect  in  women  who  are  suffering  from  uterine 
disease,  in  consequence  of  its  indirect  effect  on  nutrition,  through 
its  influence  on  the  nervous  system.  When  tea  is  taken  to  excess 
its  effect  is  equally  bad,  since  it  likewise  disturbs  digestion,  and 
destroys  all  appetite  for  animal  food.  Nutrition  becomes  so  much 
impaired  that  the  local  disease  may  be  almost  accepted  as  the  con- 
sequence, and  not  the  cause,  with  a  large  number  of  patients  who  have 
become  dependent  on  the  stimulating  effect  of  either  of  these  agents. 
In  my  private  hospital  coffee,  well  diluted  with  milk,  is  allowed  on 
but  one  day  in  the  week,  while  I  place  no  limit  on  the  use  of  weak 
tea.  When  the  use  of  tea  has  not  been  excessive,  I  find  it  even 
beneficial,  since  the  effect  of  its  moderate  use  is  that  of  a  tonic,  so 
far  as  it  arrests  the  waste  of  nervous  tissue,  without  a  subsequent 
depressing  influence.  Coffee,  on  the  contrary,  is  a  powerful  nerve 
stimulant,  but  its  use  is  always  followed  by  a  stage  of  depression,  well 
marked  in  a  class  of  cases  already  suffering  more  or  less  from  nervous 
derangement. 

I  have  already  referred  in  a  brief  manner  to  the  abuse  of  stimu- 
lants and  anodynes ;  but  before  closing  the  subject  of  general  treat- 
ment it  is  necessary  that  I  should  again  consider  these  agents  in 
relation  to  their  legitimate  use. 

Stimulants  are  often  very  beneficial,  when  occasionally  taken  with 
the  food  to  assist  digestion,  and,  under  proper  direction,  as  a  remedial 
affent.  But  we  are  all  cocrnizant  of  the  fact  that  there  are  many  in- 
stances  where  the  use  of  stimulants  has  become  a  confirmed  habit, 
through  the  culpable  error  of  the  physician  in  ordering  them  without 
proper  and  explicit  directions.  But  few  women  are  safe  after  once 
thev  have  fully  experienced  the  grateful  increase  of  strength  tempo- 
rarily induced  by  these  agents.  This  is  due  to  the  fact  that  they 
suffer,  at  times,  from  a  degree  of  prostration  attending  diseases  of 
their  organs  of  generation,  seldom  experienced  by  the  other  sex.  From 
the  use  of  these  agents,  as  with  coffee,  the  state  of  prostration  is  often 
very  great  with  some  Avomen,  on  account  of  the  condition  of  their 
nervous  system.  A  frequent  resort  to  stimulants  becomes,  therefore, 
more  necessary  to  them  than  to  men,  and  consequently  the  habit  of 
intemperance  is  more  easily  acquired  by  sick  women.  This,  however, 
is  not  true  with  them  in  a  state  of  health,  since  the  innate  sense  of 


104  PRINCIPLES    OF    GENERAL    TREATMENT. 

duty  and  moral  obligation  is  so  much  stronger  in  woman,  that  she 
would  be  less  likely  than  man  to  yield  to  temptation. 

I  frequently  direct  that  one  or  two  wineglasses  of  good  claret, 
Burgundy,  or  dry  sherry  be  taken  with  the  principal  meal  in  the  mid- 
dle of  the  day  ;  and  when  a  patient  is  very  feeble,  I  sometimes  order 
a  glass  of  sherry  with  a  fresh  egg  beaten  up  in  it,  to  be  given  with  a 
cracker  before  breakfast.  Stimulants  are  frequently  ordered  to  be 
taken  on  an  empty  stomach  at  bedtime,  when  a  patient  is  habitually 
wakeful.  This  I  believe  to  be  very  injurious,  since  the  digestion  is 
likely  to  be  deranged  from  it  on  the  following  day  ;  and  the  practice 
cannot  be  continued,  even  for  a  short  time,  without  establishing  it  as 
a  necessity.  It  is  better  instead  to  give  some  light  food,  which  will  often 
relieve  the  brain  sufficiently,  as  digestion  takes  place,  to  cause  sleep. 
Unless  the  claret  had  some  body,  such  as  Burgundy  possesses,  it  is 
liable  to  become  acid,  and,  on  this  account  is  better  taken  pure  than 
diluted.  These  wines,  by  aiding  digestion,  improve  rapidly  the 
quality  and  quantity  of  the  blood,  while  the  use  of  whisky  is  of  little 
if  any  benefit  in  this  respect. 

To  relieve  the  sudden  and  distressing  sinking  sensation,  due  to 
deficient  action  in  the  solar  plexus,  and  to  which,  females  sufiering 
from  any  uterine  disorder  are  so  liable,  a  camphor  mixture,  comp.  spts. 
of  lavender,  aromatic  spts.  of  ammonia,  or  the  ammoniated  tincture 
of  valerian,  will  be  found  to  answer  better  than  any  stimulant  of  an 
alcoholic  character.  As  soon  as  the  patient  is  able  to  exercise  in  the 
open  air,  all  stimulus  had  better  be  discarded,  unless  there  should 
exist  some  reason  to  the  contrary,  and  reliance  be  placed  on  the  good 
effects  of  fresh  air  and  sunlight. 

On  the  administration  of  anodynes  there  remains  but  little  addi- 
tional to  be  said,  beyond  reiterating  the  necessity  for  exercising  great 
caution  in  their  use.  Giving  these  remedies  to  relieve  the  many  bad 
feelings  and  sleeplessness  of  nervous  bed-ridden  women  is  a  great 
error  in  practice,  since  their  use  but  adds  to  the  difficulty,  with  the 
certainty,  almost,  of  creating  the  habit  of  dependence  upon  them. 
These  symptoms  are  but  the  outcries  of  nature  indicative  of  the  want 
of  fresh  air,  sunlight,  and  a  better  regulated  circulation  of  the  blood ;  so 
that  every  step  taken  to  affi)rd  the  patient  the  benefits  of  these  essen- 
tials is  made  in  the  proper  direction.  The  difibrent  means  already 
suggested  musf  be  employed,  and,  to  improve  the  condition  of  the 
circulation,  the  surface  of  the  body  and  extremities  are  to  be  fre- 
quently and  thoroughly  rubbed.  Rubbing  and  mild  massage  can  be 
very  advantageously  employed  to  relieve  the  restlessness  and  wake- 


DANGERS  OF  LONG  REST  IN  BED.  105 

fulness  of  a  person  unable  to  exercise.  Other  local  means  will  be 
referred  to  hereafter,  but  this  method  must  be  employed  to  an  extent 
sufficient  to  cause  the  patient  to  fall  asleep  from  sheer  fatigue.  The 
different  preparations  of  bromine,  iodine,  calcium,  and  ammonia 
will  be  found  most  useful.  Some  light  but  concentrated  food  given 
at  bedtime,  after  a  thorough  rubbing,  will  often  produce  a  good 
night's  rest,  and  this  is  further  advisable,  since  the  whole  night  is 
often  too  long  a  period  for  many  patients  to  fast.  We  must,  tlien, 
by  one  substitute  or  another,  gain  time  and  avoid,  if  possible,  the 
resort  to  chloral  or  opium  in  any  form. 

Unless  the  patient  be  suffering  from  inflammation,  as  from  an  attack 
of  cellulitis,  where  rest  is  essential,  she  must  be  gotten  out  of  bed 
and  into  the  open  air  as  soon  as  possible.  There  never  was  a  greater 
fallacy  in  practice  than  to  place  in  bed  a  woman  suffering  from  ute- 
rine disease,  with  the  expectation  that  she  would  recover  her  health 
by  remaining  there.  The  loss  of  tone  to  her  general  condition  will 
be  greater  than  any  benefit  to  be  gained  from  the  confinement,  even 
when  combined  with  a  well-judged  course  of  local  treatment.  She 
will  not  be  confined  long  in  bed  before  her  general  health  must  become 
so  far  affected  as  to  make  her  more  sensitive  to  all  nervous  impressions. 
At  length,  if  an  attempt  be  made  to  sit  up,  the  actual  suffering,  pro- 
duced by  the  blood  again  distending  the  vessels,  when  in  the  upright 
position,  will  cause  her  to  desist  from  the  attempt.  After  having 
remained  in  the  horizontal  posture  for  a  length  of  time,  the  vessels 
of  course  diminish  greatly  in  calibre,  being  relieved  of  the  weight  of 
the  column  of  blood.  When  assuming  the  upright  position,  these 
vessels  are  again  distended,  and  few  patients  have  the  courage  to  per- 
severe, since  they  ahvays  attribute  the  suffering  to  the  continued  ex- 
istence of  the  local  disease.  Women  are  sometimes  able  to  remain 
for  years  in  bed  without  their  general  health  apparently  suffering  from 
the  confinement.  This  degree  of  tolerance,  hoAvever,  is  not  brought 
about  until  a  stage  of  acclimatation  (adaptation),  as  it  Avere,  is  gone 
through  with,  during  which  time  the  general  health  suffers.  In  the 
end,  the  local  disease  may  improve,  or  even  disappear  by  the  rest, 
yet,  in  spite  of  an  improvement  in  the  general  health,  the  patient  will 
remain  an  invalid,  as  she  will  have  already  contracted  the  habit  of 
being  sick.  This  is  the  history  of  becoming  a  confirmed  invalid,  due, 
in  the  beginning,  entirely  to  the  ignorance,  to  the  indifference,  or  to 
the  want  of  an  honest  purpose  on  the  part  of  the  attending  physician. 
We  may  charitably  attribute  the  result  to  ignorance,  in  the  greater 
number  of  cases,  and  to  a  degree  of  ignorance  which  would  not  be 


106  PRINCIPLES    OF    GENERAL    TREATMENT. 

tolerated  in  the  practice  of  any  other  branch  of  the  profession. 
There  is  a  stage  in  the  progress  of  nearly  all  diseases  of  the  female 
organs  of  generation,  developing  in  early  life,  which,  if  recognized 
and  properly  treated,  may  end  in  a  complete  restoration  to  health, 

A  young  girl  should  never  be  subjected  to  a  physical  examination 
without  the  fullest  indication  of  its  necessity,  nor  should  the  examina- 
tion be  made  by  one  incompetent  to  judge  fully  of  her  condition.  But 
nevertheless  she  is  not  free  from  a  certain  liability  to  local  disease, 
the  result  of  accident  or  imprudence.  She  may,  for  example,  have  a 
fall  producing  retroversion  of  the  uterus,  or  by  getting  her  feet  wet, 
suffer  from  an  attack  of  local  cellulitis.  Surely  the  medical  man  in 
charge  would  be  culpable  if,  through  consciousness  of  his  inability  to 
make  a  diagnosis,  or  from  indifference  as  to  the  result,  an  investiga- 
tion were  withheld  on  the  plea  of  her  youth.  The  instances  are  com- 
mon in  which  such  cases  are  neglected  at  the  beginning,  for  the  reason 
assigned,  and  the  assurance  is  given  that  relief  will  be  obtained  by 
rest  and  time.  Too  often  the  fulfilment  of  the  promise  is  not  made 
good,  and  the  patient  comes  to  be  a  confirmed  invalid,  and  to  depend 
on  the  use  of  stimulants  or  anodynes.  Let  us  suppose  the  case  of  a 
young  girl  seized  with  diarrhoea,  whose  physician,  after  directing  that 
she  should  be  kept  quiet,  Avere  to  make  no  further  investigation  out  of 
respect  to  her  modesty,  but  should  alloAV  the  case  to  drag  on  until  it 
was  thought  that  she  was  old  enough  for  an  examination.  Let  it  be 
then  found  that  the  diarrhoea  had  become  chronic,  with  ulceration  and 
thickening  of  the  whole  colon.  Should  the  responsibility  of  the 
physician  cease  in  the  case  when  he  advises  the  patient  to  consult 
some  one  who  had  paid  more  attention  to  such  diseases  than  he  had  ? 
But  no  physician  would  allow  the  diarrhoea  to  go  on  without  informing 
himself  as  far  as  possible  of  its  cause,  and  he  would  employ  every 
means  at  his  command,  and  act  on  the  advice  of  others,  to  check  its 
progress.  Such  results  of  ignorance  or  neglect  are  often  met  with 
in  gynsecological  practice  ;  and  the  cause  which  I  have  supposed  in 
this  instance  is  only  one  of  many  equally  simple,  which  are  capable 
of  originating  grave  disorders.  We  may  also  call  attention  to  the  evil 
consequences  of  failure  to  fully  investigate  the  case,  not  only  of  young 
girls  but  of  Avomen  of  any  age.  Often  time  is  thus  lost,  and  the 
patient  even  rendered  incurable,  by  the  mistaking  of  a  symptom  for  the 
disease.  Can  we  cite  a  more  common  instance  than  that  of  retrover- 
sion, when  the  displacement  is  frequently  never  suspected,  and  months 
are  lost  in  attempting  to  treat  the  first  and  only  condition  detected 


BED-RIDDEN    PATIENTS.  107 

in  the  case,  viz.,  a  supposed  ulceration  on  the  cervix,  a  lesion  of  little 
consecpience,  and  one  -which  Avould  likely  disappear  on  correcting  the 
displacement,  and  restoring  the  circulation  in  the  organ  ?  The  bad 
health  of  many  a  woman  has  begun  in  a  simple  displacement,  and 
ended  in  her  becoming  bed-ridden  from  recurrent  attacks  of  cellulitis, 
or  from  the  irritation  extending  to  one  of  the  ovaries,  producing  en- 
largement and  prolapse. 

There  are  many  instances  where  women  have  become  bed-ridden 
in  consequence  of  too  much  importance  being  attached  to  the  local 
condition,  by  the  physician,  or  where  he  has  failed  to  check  by  the 
exercise  of  a  stronger  will  the  growing  tendency  on  the  part  of  the 
patient  to  chronic  invalidism.  These  women  are  always  most  intelli- 
gent and  plausible,  but  with  a  full  development  of  the  nervous  element. 
After  a  certain  time  has  been  spent  in  bed  no  amount  of  argument 
can  be  advanced  to  make  the  slightest  impression ;  in  fact  the  physi- 
cian is  helpless,  since  every  point  he  may  take  will  be  ably  refuted. 
I  have  been  consulted  by  cases  of  this  description  when  not  the 
slightest  evidence  of  any  uterine  disease  could  be  detected.  Yet 
they  would  continue  to  remain  bed-ridden  until  a  fortunate  fire,  a  fit 
of  anger,  or  some  other  powerful  stimulus,  brings  by  accident  the  re- 
lief they  have  not  been  able  to  obtain.  Notwithstanding  this  subject 
has  already  been  treated  of  at  great  length,  its  importance  will  justify 
the  recital  of  two  instances,  which,  among  others,  have  passed  under 
my  observation,  to  illustrate  how  much  may  sometimes  be  accomplished 
under  favorable  circumstances. 

Several  years  ago  I  was  sent  for  to  see  a  young  married  lady, 
residing  in  the  western  part  of  this  State,  who  had  been  a  helpless  in- 
valid, and  confined  to  her  bed  for  some  five  years.  I  made  my  exami- 
nation about  nine  o'clock  in  the  morning,  but  with  great  difficulty  on 
account  of  her  apparent  feebleness.  In  fact  she  would  have  deferred 
the  examination  on  account  of  her  condition,  were  it  not  that  great 
importance  had  been  attached  to  my  visit,  which  had  been  unavoidably 
put  off  several  times  on  account  of  my  business.  I  was  surprised  to 
find  no  uterine  difficulty  except  a  slight  degree  of  retroversion,  and  the 
organ  rather  lower  in  the  vagina  than  natural.  Certainly  nothing  to 
keep  her  in  bed,  as  there  was  not  the  slightest  tenderness  to  be  detected 
by  the  finger  at  any  point.  I  was  puzzled  to  make  up  my  mind  as  to 
what  course  to  pursue,  for  I  was  satisfied  that  if  any  local  disease  had 
ever  existed  it  had  gotten  well  without  her  being  aware  of  the  fact. 
I  felt  that  it  was  necessary  to  get  her  out  of  bed,  without  the  mortifi- 
cation of  knowing  that  no  local  disease  existed,  and  that  I  would  fail 


108  PRINCIPLES    OF    GENERAL    TREATMENT. 

if  she  were  told  the  true  condition.  It  was  Sunday  ;  I  was  obliged  to 
remain  until  night  before  the  arrival  of  the  train  ;  it  was  in  the  country 
and  in  the  midst  of  a  snow-storm  ;  there  were  some  eight  hom^s  at  my 
disposal,  and  I  determined  to  devote  the  day  to  her  case,  and  see  what 
could  be  accomplished  by  force  of  will,  after  gaining  her  confidence.  I 
first  entered  into  the  fullest  detail  of  her  past  history,  but  could  elicit 
from  her  little  more  than  monosyllables.  I  then  branched  into  litera- 
ture, science,  and  the  arts  to  the  fullest  extent  of  my  knowledge,  but 
at  the  end  of  two  hours  I  had  apparently  made  no  impression,  and  was 
almost  in  despair  of  being  able  to  find  any  subject  of  common  interest 
to  us.  At  length  a  casual  remark  about  autographs  promised  better, 
for  I  then  learned  that  in  the  garret  there  was  stored  away  a  collec- 
tion made  by  her  a  number  of  years  before.  I  had  it  hunted  up,  and 
soon  found  that  I  was  making  progress.  I  gradually  got  her  interested 
sufficiently  to  lie  on  her  elbow,  and  tell  me  all  the  particulars  as  to  who 
the  local  celebrities  were,  and  under  what  circumstances  each  letter 
had  come  into  her  possession.  After  I  had  talked  steadily  for  more 
than  two,  and  she  for  three  hours,  we  had  become  the  best  of  friends, 
and  I  began  to  think  of  getting  her  up  to  dinner.  I  suddenly  asked, 
"  Are  you  not  now  relieved  of  that  feeling  of  great  pressure  from  which 
you  have  suffered  so  long?"  With  an  expression  of  surprise,  she  said, 
"  Why,  yes,  entirely  so."  "  That  is  just  as  T  expected,"  I  remarked, 
"  so  we  will  send  for  your  maid  to  get  you  read}^  for  dinner,  since  you 
are  not  going  to  let  your  husband  and  myself  dine  alone  when  you  are 
so  much  relieved."  "  Doctor,  are  you  serious,  do  you  think  that  I 
can  get  up  ?"  "  Certainly,  I  know  that  you  can ;  and  for  what  purpose 
did  I  come  from  such  a  distance,  but  to  relieve  you?" 

I  had  her  limbs  thoroughly  rubbed,  clothing  hunted  up,  and  then 
assisted  her  in  to  dinner.  She  occupied  a  seat  alongside  of  me,  and 
I  exerted  myself  to  the  utmost  to  keep  her  interested,  and  the  conver- 
sation from  flagging.  After  the  lapse  of  half  an  hour  I  saw  that  she 
was  too  much  exhausted  to  remain  up  longer,  although  she  was  making 
every  effort.  She  remain*ed  lying  on  the  sofa  for  an  hour  or  two, 
and  then,  at  my  suggestion,  walked  with  the  aid  of  her  maid  up  and 
doAvn  the  entry  for  a  while,  ^'  to  test  what  I  had  done."  AVhen  I 
left  the  house  for  the  train,  she  waved  a  farewell  to  me  from  her  bed- 
room window.  Two  weeks  afterwards  she  walked  into  my  office  in 
New  York,  and  has  since  been  well. 

This  case  was  one  in  which  the  physician  supposed  some  local  dis- 
ease existed,  and  had  insisted  on  her  remaining  in  bed.  Iler  general 
health  soon  began  to  suffer;  she  afterwards  regained  her  strength,  but 


PERSONAL    INFLUENCE.  109 

the  habits  of  an  invalid  were  then  so  confirmed  that  she  continued 
bedridden.  Fortunately  for  her,  she  was  over-impressed  with  the 
importance  of  my  visit,  and  almost  prepared  for  the  performance  of 
some  miracle  as  the  result  of  my  skill.  Yet,  withal,  I  should  have 
accomplished  nothing,  but  for  the  fortunate  circumstance  of  the  auto- 
graphs, by  which  I  was  enabled  to  get  under  the  shell  and  gain  her 
personal  confidence. 

With  the  history  of  this  case  before  us,  it  Avill  not  be  out  of  place 
to  refer  again  to  the  absolute  necessity  of  gaining  this  personal  in- 
fluence over  a  certain  class  of  patients  before  any  great  advance  can 
be  made  in  the  treatment.  It  is  not  sufficient  alone  that  the  patient 
should  have  every  confidence  in  the  skill  of  her  physician,  for,  in 
certain  conditions  of  the  nervous  system,  it  will  avail  little  without  the 
personal  influence.  There  lies  the  great  difficulty,  and  one  often 
insurmountable,  of  ever  gaining  this  influence,  through  either  confi- 
dence or  fear,  over  a  patient  treated  at  home,  and  surrounded  by 
sympathizing  friends.  I  have  labored  for  hours  and  days,  without 
the  patient  being  conscious  of  it,  to  gain  this  influence  and  to  create  a 
feeling  of  dependence.  With  it  comes,  on  her  part,  the  firm  con- 
viction of  her  recovery.  As  I  study  her  peculiarities,  I  gain  a  more 
accurate  knowledge  of  the  inner  woman  than  she  herself  possesses, 
by  getting  at  the  deep  under-currents  which  may  have  been  running 
awry,  through  the  greater  part  of  her  life,  and  to  the  detriment  of  her 
nervous  system.  She,  herself,  will  give  me  all  the  information  I  need, 
with  the  confidence  of  a  child,  yet,  afterwards,  will  credit  me  Avith 
a  degree  of  penetration  undeserved,  but  with  the  effect  of  adding 
greatly  to  my  influence.  To  attain  this  point  fully  repays  the  physi- 
cian for  his  labor,  since  the  patient  then  loses  sight  of  herself,  and  is 
only  anxious  to  carry  out  his  views  without  question,  and  simply 
because  he  Avishes  it.  This  influence  enables  a  patient  to  keep  her 
nervous  feelings  under  a  healthy  discipline,  so  much  so,  that  nothing 
would  mortify  a  patient  in  my  private  hospital  more,  than  for  me  to 
doubt  her  power  of  self-control.  This  influence  is  not  to  be  gained 
by  any  degree  of  intimacy  or  sympathy,  but  rather  the  contrary. 
When  necessary  to  accomplish  it,  I  aim  to  gain  absolute  and  entire 
control  over  the  patient,  to  understand  every  thought  and  motive,  and. 
to  direct  her  as  a  child.  Those  who  suffer  from  hysterical  disturbances 
or  other  nervous  disorders  cannot  be  properly  controlled  and  directed 
without  the  exercise  of  this  influence  by  a  Avill  stronger  than  their 
own.  I  have  met  with  other  instances  where  they  have  become 
intensely  selfish  and  willful,  so  much  so,  that  no  influence  could  be 


110  PRINCIPLES    OF    GENERAL    TREATMENT. 

exercised  over  them,  except  through  fear,  and  to  get  them  out  of  bed 
is  an  act  of  kindness,  in  the  end,  even  if  it  becomes  necessary  to 
employ  force. 

About  eight  years  ago,  a  young  unmarried  woman  was  brought  to 
me  from  one  of  the  New  England  States,  through  the  advice  of  Dr. 
Wm.  H.  Van  Buren,  of  this  city.  She  was  moved  on  a  stretcher, 
with  great  difl&culty,  and  had  been  confined  to  her  bed  for  some  four 
years.  She  had  indeed  become  a  skeleton  in  the  house,  from  the 
amount  of  attention  she  required,  as  she  was  unable  to  feed  herself 
or  move  without  help,  and  would  only  sleep  at  night  with  the  gas 
burning  brightly,  and  with  some  member  of  the  family  to  sit  up  with 
her.  Moreover,  she  was  so  willful,  that  to  annoy  those  in  charge  of 
her,  she  would  sometimes  deliberately  have  a  movement  of  the  bowels 
or  empty  her  bladder  in  bed.  When  I  attempted  to  examine  her,  she 
persisted  in  keeping  her  limbs  rigid  and  straight  out,  she  would  not 
answer  a  question,  and  lay  with  her  eyes  shut.  By  watching  the 
expression  of  her  face,  I  judged  that  every  portion  of  the  vagina  was 
painful  on  pressure,  and  yet  I  was  not  sure  but  that  she  was  enjoying 
a  little  spiteful  pleasure  in  misleading  me.  I,  however,  could  detect  no 
disease  except  that  the  uterus  was  rather  larger  than  natural,  and  very 
much  anteverted.  The  father,  mother,  an  aunt,  and  several  members 
of  the  family  were  anxiously  waiting  to  hear  the  result  of  my  investi- 
gation. They  had  come  prepared  to  spend  the  winter,  and  be  on  the 
spot  while  the  patient  was  under  treatment.  This  circumstance  em- 
barrassed me  more  than  the  condition  of  the  patient,  but  I  quickly 
determined  on  the  course  to  be  followed.  I  told  the  father  that  I  had 
found  out  the  difiiculty,  but  it  was  necessary  that  I  should  not  enter 
into  any  further  particulars,  and,  to  enable  me  carry  out  my  plan,  he 
and  his  family  must  return  home  by  the  next  train,  and  without  taking 
leave  of  the  daughter.  If  they  did  this,  I  felt  certain  that  I  could 
cure  her,  and  if  unwilling,  they  must  seek  the  advice  of  some  one 
else.  As  I  went  on,  attending  to  my  business,  they  remained  staring 
at  me  in  a  state  of  surprise,  Avith  great  indignation,  and  did  not  make 
up  their  minds  as  to  the  course  to  pursue  until  the  last  moment,  in 
time  to  take  the  train.  I  went  up  to  see  her  afterwards,  and  found 
her  lying  with  her  eyes  closed  as  I  had  left  her.  I  remarked,  "  Well 
you  are  now  fairly  in  the  hands  of  the  Philistines,  for  your  father, 
mother,  aunt,  and  all  of  them  have  returned  home  without  even 
bidding  you  good-bye,  and  I  have  now  got  you  entirely  in  my  power." 
I  saw  that  I  had  made  an  impression,  but  she  soon  recovered  herself. 
I  told  her  all  in  the  house  were  but  parts  of  a  machine,  with  no 


MORAL    MANAGEMENT.  Ill 

thought  beyond  carrying  out  my  instructions.  That  I  was  a  very 
devil  when  roused,  and  bade  her  look  at  nie  well,  and  see  if  she  did 
not  think  I  Avas  fearfvdly  in  earnest.  I  noticed  that  her  eyelids 
slightly  parted,  as  curiosity  tempted  her  to  see  if  I  was  really  what  I 
represented  myself  to  be.  I  continued,  and  stated  that  as  long  as  I 
had  my  own  way  I  was  as  gentle  as  a  lamb,  but  I  would  give  her  fair 
notice  that  she  would  live  to  regret  it  if  she  ever  deviated  from  my 
instructions.  "  To-morrow,"  I  said,  "  at  ten  o'clock,  I  will  begin  to 
see  the  patients  in  the  office,  and  you  must  be  dressed  at  that  time.  I 
will  call  for  you,  and  if  you  are  not  dressed,  I  will  play  the  lady's 
maid,  and  with  no  light  hand,  for  it  will  be  a  very  busy  part  of  the  day 
with  me.  I  shall  remove  that  nightgown,  and  put  on  your  flannel 
underskirt,"  etc.  I  then  slowly  enumerated,  in  order,  every  article 
of  female  dress  I  could  think  of,  even  to  a  napkin.  This  was  too 
much  for  her,  and  she  opened  her  eyes,  saying  "  You  are  a  brute, 
sir."  I  directed  that  her  meals  should  be  placed  alongside  of  her 
bed,  that  she  might  feed  herself,  but  I  believe  she  ate  nothing.  She 
was  told,  that  until  she  could  be  civil,  she  Avould  be  left  to  herself  as 
far  as  possible.  At  nine  o'clock  her  gaslight  was  turned  out,  and  she 
was  heard  sobbing  several  times  in  the  night,  as  the  nurse  passed 
back  and  forth  in  the  passage-way.  In  the  morning,  I  learned  from 
the  nurse  that  she  evidently  intended  to  have  it  out,  and  that  nothing 
whatever  could  be  done  with  her.  At  ten  o'clock  I  entered  her  room, 
but  her  courage  had  failed  her  at  the  last  moment,  on  hearing  my 
footsteps,  and  she  was  Avildly  trying  to  pull  on  a  stocking  under  the 
bedclothing.  I  saw  at  a  glance  that  I  had  conquered.  I  spoke  to 
her  kindly,  bid  her  lie  down,  and  said  that  I  was  glad  to  see  she  had 
made  up  her  mind  to  help  me,  and  as  she  was  still  fatigued  from  her 
journey,  she  could  rest  until  the  next  day,  but  that  she  must  then  be 
up.  Daring  the  day  she  was  quite  friendly  with  the  nurses,  and  the 
next  morning  I  found  her  dressed  with  their  aid.  I  gave  her  my  arm 
to  assist  her  to  the  elevator,  helped  her  into  the  office,  and  made  a 
most  satisfactory  examination.  She  remained  for  half  an  hour  on  a 
sofa  in  the  parlor,  and  then  I  allowed  her  to  return  to  her  room.  In 
a  few  days  she  was  out  riding  in  a  carriage,  soon  she  Avas  able  to 
walk  out,  and  at  the  end  of  a  month  she  returned  home  well.  She 
became  very  much  attached  to  me  in  a  few  days,  and  I  never  had  a 
more  tractable  patient.  The  treatment  consisted  in  hot-water  vaginal 
injections  daily,  several  applications  of  iodine  over  the  whole  vaginal 
canal.     She  was  also  well  rubbed  twice  a  dav,  from  head  to  foot,  had 


112  PRINCIPLES    OF    GENERAL    TREATMENT. 

all  the  fresh  air  and  sunlight  she  could  get,  and  some  medicine  to 
regulate  the  bowels. 

At  the  risk  of  being  tedious  I  have  entered  more  into  a  detailed 
history  of  these  two  cases  than  at  first  glance  might  seem  called  for. 
The  contrast  between  the  two  cases  was  very  great ;  and  it  was  neces- 
sary that  the  plan  of  treatment  should  be  different.  The  first  patient 
had  preserved  all  the  characteristics  of  her  sex,  and  through  a  sense 
of  duty,  might  at  any  time  have  made  the  effort  to  throw  off  the 
habits  of  an  invalid.  At  least  she  would  not  willfully  have  refused  to 
listen  to  advice,  although  she  may  have  felt  satisfied,  she  could  not 
follow  it.  But,  with  the  last  case  there  was  but  little  more  than  the 
instincts  of  the  animal  left,  for  she  was  not  moved  through  any  sense 
of  modesty,  but  from  fear,  as  she  acknowledged  afterwards,  that  she 
thought  I  looked  as  if  I  might  spank  her.  I  was  aided  through  the 
helpless  condition  she  felt  herself  in,  alone  among  strangers,  and 
through  fear  of  punishment  she  was  conquered.  But  after  she  had  once 
yielded,  and  all  were  now  kind  to  her,  it  Avas  not  necessary  for  me  to 
tell  her  to  make  the  exertion,  for  she  knew  that  I  Avished  it,  and  this 
excited  a  desire  on  her  part  to  prove  herself  worthy  of  my  confidence. 
In  a  kind  manner  I  had  quietly  pointed  out  to  her  certain  serious  de- 
fects which  it  was  advisable  for  her  to  correct.  The  effort  then  made 
by  her  to  carry  out  a  purpose  in  overcoming  her  temper,  and  sub- 
jecting herself  to  this  self-discipline,  brought  out  all  the  good  traits  of 
her  character. 

To  carefully  w^atch  for  and  check  any  disposition  on  the  part  of  the 
patient  to  fall  into  the  habits  of  an  invalid  is  quite  as  much  a  part  of 
the  duty  of  the  physician  as  to  prescribe  for  her  general  health,  or  to 
treat  her  local  condition.  Unless  there  should  be  a  necessity  for  re- 
maining in  bed,  the  physician  should  insist  upon  the  patient  being 
regularly  dressed  every  day,  not  to  remain  in  a  Avrapper  or  dressing 
gown,  but  to  complete  her  toilet  as  if  she  Avere  going  out.  Let  it  be 
the  exception  to  the  rule  that  breakfast  be  taken  in  bed,  for  this  is  a 
bad  beginning  for  the  day.  When  unable  to  go  to  her  meals,  at  least 
require  that  the  breakfast  shall  be  served  in  another  room,  even  if  she 
has  to  be  carried  there,  that  in  the  mean  time  her  OAvn  may  be  properly 
aired  for  the  day.  So  long  as  this  discipline  can  be  enforced  the 
probabilities  of  becoming  bed-ridden  will  be  kept  in  abeyance.  I  have 
often  accepted,  Avith  no  little  satisfaction,  the  addition  of  an  extra 
ribbon  or  boAV  to  the  toilet,  or  the  Avearing  of  a  trim  breakfast  cap  as 
a  hopeful  promise  for  the  future.  Let  the  patient  then  dress  herself 
each  day  as  if  she  expected  to  receive  visitors,  and  even  be  encouraged 


DISCIPLINE — DRESS.  113 

to  put  on  her  best  to  make  her  appearance  as  attractive  as  possible. 
When  necessary  I  insist  on  this  being  done  as  a  matter  of  respect  to 
myself.  Notwithstanding  the  exertion  is  a  fatiguing  one,  it  occupies 
her  mind,  and  will  impart  a  healthful  impression  to  the  effect  that 
she  is  not  as  sick  as  she  would  feel  were  she  to  remain  in  bed.  The 
difficulties  to  be  overcome  seem,  sometimes,  almost  insurmountable  in 
carrying  out  any  plan  of  discipline  as  has  been  advised.  Yet  it  is 
beyond  question  the  duty  of  the  physician  to  persevere  in  the  effort 
to  the  end,  and  even  if  a  compromise  has  to  be  made,  what  is  gained 
will  aid  him  greatly  in  the  successful  management  of  the  case.  I  am 
always  on  the  lookout  to  turn  every  circumstance  to  my  advantage, 
and  have  frequently  prescribed  some  article  of  dress  as  I  would  a 
tonic. 

Two  years  ago  a  lady  from  the  South  came  under  my  charge,  who 
had  been  confined  to  her  room  about  six  years,  that  is,  since  the  birth 
of  her  last  child.  She  was  not  bed-ridden,  but  had  suffered  after  her 
confinement  from  so  much  pain  and  bearing  down,  when  on  her  feet, 
that  she  had  gradually  fallen  into  the  habits  of  an  invalid.  She 
AYOuld  seldom  remain  in  bed  all  day,  but  would  be  partially  dressed, 
when  she  felt  so  disposed,  and  then  lie  on  the  bed  or  sofa  m  a  wrapper. 
I  found,  having  been  confined  to  her  room  so  long,  that  her  wardrobe 
was  so  far  incomplete  as  to  be  wanting  in  a  dress.  To  the  surprise 
of  herself  and  friends,  my  first  prescription  was  a  hoop-skirt  and  a 
black  silk  morning  dress  to  be  made  in  the  latest  fashion.  I  insisted 
on  having  these  procured  before  doing  anything  else,  and  as  I  found 
out  that  she  had  never  Avorn  a  hoop-skirt  I  looked  forward  with  great 
interest  to  its  beneficial  effect.  By  my  direction,  she  was  dressed  in 
full  one  morning,  but  I  believe  the  hoop-skirt  was  not  a  success, 
from  the  difficulty  in  arranging  it  as  she  lay  on  the  bed.  But  I  con- 
fiscated the  wrapper,  and,  as  if  by  accident,  had  her  left  alone.  My 
anticipations  Avere  fully  realized,  for,  on  going  into  the  room  shortly 
afterwards,  I  found  that  her  curiosity  had  conquered,  for  she  was  in 
front  of  the  looking-glass  observing  the  general  effect,  and  arranging 
her  hoop-skirt.  I  had  also  ordered  a  fashionable  style  of  bonnet  to  be 
purchased,  Avhich  Avas  then  put  on  and  she  Avas  sent  out  for  a  driA-e 
before  she  had  time  fairly  to  realize  the  situation.  Having  thus  once 
broken  the  spell,  the  treatment  of  her  case  progressed  rapidly. 

NotAvithstanding  the  capillary  circulation  is  so  feeble  in  many 
women,  they  do  not  require,  for  their  comfort,  as  much  clothing  to 
protect  them  from  the  cold  as  do  men.  Although  they  may  experience 
no  sense  of  discomfort  at  the  time,  yet  the  exposure  to  Avhich  they 


114  PRINCIPLES    OF    GENERAL    TREATMENT. 

are  subjected,  even  for  healthy  women,  is  attended  with  deleterious 
effects  on  the  circulation  of  the  skin  and  extremities,  by  leading  to 
habitual  congestion  of  the  viscera.  In  an  equable  climate,  nature 
might  establish  from  habit  a  degree  of  tolerance,  but,  subjected  as 
we  are  to  such  great  and  sudden  atmospheric  changes,  it  is  impossible 
always  to  escape  the  consequences,  even  Avith  careful  forethought. 
Most  men  would  perish  from  the  effects  of  exposure  were  they 
no  better  protected  than  women  who  ordinarily  are  the  more  pru- 
dent. After  excluding  the  bad  effects  which  sometimes  follow  child- 
birth and  the  results  of  accident,  it  will  be  found,  I  am  satisfied,  that 
the  great  cause  of  disease  in  woman  is  to  be  traced  to  the  effect  of 
exposure  from  insufficient  clothing.  It  Avill  have  to  be  the  work  of 
time  before  the  public  can  be  educated  to  realize  the  necessity  for  a 
change  in  the  dress  of  women  as  well  as  in  that  of  children.  This  sub- 
ject should  specially  engage  the  careful  attention  of  the  physician  who 
has  in  charge  a  patient  suffering  from  any  disease  of  the  class  under 
consideration.  This  is  the  more  necessary,  since  in  sickness  the 
system  is  less  able  to  protect  itself  than  in  health,  and  every  means 
must  be  availed  of  to  improve  the  capillary  circulation,  so  that  the 
tendency  to  obstruction  in  the  larger  vessels  may  be  removed. 

In  winter  a  flannel  shirt  and  drawers,  to  be  worn  next  to  the  skin, 
are  essential.     In  warm  weather  a  lighter  flannel  shirt  can  be  worn, 
but  it  should  never  be  wholly  dispensed  with.     At  night,  the  flannel 
worn  through  the  day  should  be  exchanged  for  a  fresh  garment,  and, 
although  one  of  a  lighter  material  may  be  used  for  the  night,  it  can 
be  safely  laid  aside  only  by  one  in  health.     The  flannel  drawers  ought 
to  be  closed  below  the  knees  in  winter  by  an  elastic  band,  but  in  sum- 
mer they  may  be  made  open,  and  of  cotton.     Linen  is  totally  unfit 
for  our  climate,  even  in  the  warmest  Aveather,  and  I  never  allow  its 
use  at  any  season,  but  have  cotton  at  once  substituted.      Woollen 
stockings   are   necessary  in  cold  Aveather,  eA^en  when  the  woman  is 
confined  to  the  house,  since  the  floor  is  ahvays  the  coldest  part  of  the 
room,  and  the  feet  are  exposed  to  draughts.     If  appearances  are  to 
be  regarded,  the  compromise  should  be  in  covering  the  coarser  stock- 
ings Avith  a  pair  made  of  finer  material.     The  use  of  cotton  or  silk 
Avill  ansAver  in  summer  if  the  Avoman  is  not  so  feeble  as  to  suffer  from 
cold  feet  at  that  season.     Thin-soled  slippers  are  inappropriate  for  an 
invalid,  even  for  use  in  the  house,  since  the  feet  are  not  properly 
protected  imless  the  slippers  are  lined,  or  made  of  cloth.     Too  much 
care  cannot  be  given  to  the  proper  protection  of  the  feet,  and  the 
soles  of  the  shoes  should  not  only  be  thick  enough  to  keep  the  feet 


HYGIENIC    MANAGEMENT.  115 

dry,  but  also  vrarm.  To  the  absurd  habit,  and  one  too  common 
among  young  ■women,  of  walking  out  in  low  shoes,  and  with  soles 
only  fitted  for  a  ball-room,  may  be  traced  much  of  the  cellulitis  with 
its  consequences,  and  the  sterility  of  after  life.  A  flannel  petticoat 
is  now  universally  worn  in  winter,  but  it  is  seldom  long  enough.  Its 
use  in  summer  should  not  be  dispensed  with  except  in  very  warm 
weather,  and  then  it  should  be  put  on  again  in  time  to  be  a  protection 
should  the  weather  change.  A  better  plan  is  to  wear  around  the 
lower  portion  of  the  abdomen,  throughout  the  summer,  a  single  thick- 
ness of  a  flannel  bandage,  wide  enough  to  reach  from  the  hips  to  the 
umbilicus,  and  which  can  be  secured  with  tapes.  It  may  be  cut  bias 
so  as  not  to  cling  so  much  to  the  body,  while  at  the  same  time  it  will 
be  more  elastic.  The  omission  of  flannel  is  entirely  a  matter  of  habit, 
for  the  heat  is  rarely  so  great  in  our  climate  but  that  a  light  flannel 
may  at  all  times  of  the  year  be  worn  next  to  the  skin,  not  only  with 
comfort,  but  as  a  most  valuable  means  for  the  preservation  of  health. 
The  object  is  not  to  keep  the  surface  of  the  body  bathed  in  perspira- 
tion by  an  excess  of  clothing,  but  covered  by  flannel  of  a  sufficient 
thickness  to  keep  the  skin  active,  and  at  the  same  time  protect  it,  at 
all  seasons  of  the  year,  from  sudden  changes.  In  women  it  is  particu- 
larly essential  to  protect  the  lower  extremities,  for  as  long  as  the 
feet  are  cold  there  will  be  an  increased  quantity  of  blood  in  the 
pelvic  vessels.  Whenever  a  patient  is  sufi^ering  from  congestive 
hypertrophy  of  the  uterus,  or  of  one  of  the  ovaries,  or  has  still  the 
remains  of  an  old  cellulitis,  she  will  inevitably  experience  an  increase 
of  pain  about  the  pelvis  whenever  the  feet  become  cold,  and  even 
before  she  has  been  made  conscious  of  their  condition  by  any  other 
sensation. 

The  selection  of  a  room  to  be  occupied  by  an  invalid  should  be 
made  with  the  view  of  obtaining  the  greatest  amount  of  sunlight  and 
a  o-ood  outlook.  If  it  can  be  avoided,  there  should  be  no  wash-basin, 
connected  with  the  sewer,  in  the  room,  nor  a  water  closet  in  the  neigh- 
borhood, since  women  who  are  debilated  from  diseases  of  the  genital 
organs  are  particularly  susceptible  to  the  poisonous  influence  of  sewer- 
gas  and  malaria.  As  long  as  the  patient  is  able  to  leave  her  room,  she 
will  be  able  to  find  occupation  for  both  body  and  mind.  But  when 
unable  to  do  so,  every  means  must  be  employed  with  the  view  of 
breaking  in  upon  a  life  which  can  be  but  a  monotonous  one  under  the 
most  favorable  circumstances.  With  this  object,  it  is  necessary  to 
move  the  furniture  and  pictures  frequently,  not  only  from  one  part  of 


116  PRINCIPLES    OF    GENERAL    TREATMENT. 

the  room  to  another,  but  to  substitute  others  when  practicable,  and 
the  position  of  the  bed  itself  should  be  frequently  changed. 

Whenever  the  system  has  become  weakened,  the  strength  of  both 
body  and  mind  must  equally  suffer.  A  woman  in  this  condition  can 
rarely  be  restored  to  health  by  any  local  treatment,  or  by  tonics  and 
some  attention  to  regulating  the  bowels,  yet  this  is  the  course  gene- 
rally followed.  It  is  really  necessary  to  give  occupation  to  both  body 
and  mind,  that  her  life  may  be  modelled  in  accordance  with  an  explicit 
course  directed  by  the  physician.  The  main  object  is  to  bring 
about  the  utmost  degree  of  regularity  in  all  her  habits,  by  which 
course  alone  we  can  hope  to  eifect  a  change  for  the  better  in  the 
function  of  nutrition.  Moreover,  from  the  well-recognized  influence 
of  the  mind  on  the  body,  in  these  diseases,  it  is  equally  essential  that 
it  should  be  kept  constantly  occupied  under  such  influences  as  are  the 
most  conducive  to  health.  It  is  a  serious  complication  for  a  physician 
to  have  in  charge  a  woman,  from  the  upper  walks  of  life,  without 
occupation  or  tastes  that  may  be  so  directed  as  to  afford  her  some 
congenial  employment.  Among  the  poorer  classes  this  is  not  so 
necessary,  since  the  brain  is  less  active,  and  with  them  it  is  more  a 
question  of  rest,  better  diet,  and  time. 

The  hours  for  meals  should  be  designated,  that  for  dinner  being 
placed  between  one  and  two  o'clock.  The  hour  for  retiring  should 
not  be  later  than  ten  o'clock,  and,  as  a  woman,  even  in  health,  needs 
more  sleep  than  a  man,  she  will  require  at  least  nine  hours.  The 
amount  of  exercise  to  be  taken  must  be  regulated  each  day  by  the 
physician,  in  accordance  with  the  progress  made,  and  the  special 
nature  of  the  treatment ;  the  best  hour,  except  in  summer,  being  about 
noon.  Even  receiving  friends,  reading,  and  employment  in  needle- 
work, drawing,  or  any  other  occupation,  I  am  obliged  frequently  to 
insist  shall  be  done  at  some  stated  hour.  But  when  I  find  a  patient 
appreciating  the  necessity  of  regularity,  and  anxious  to  occupy  her 
time  properly,  I  prefer  to  leave  the  details  to  herself,  as  an  additional 
source  of  occupation.  The  great  problem,  in  nearly  every  case, 
which  will  tax  both  the  skill  and  patience  of  the  physician  to  solve, 
is  to  regulate  the  bowels,  with  the  least  resort  to  medicine,  and 
to  establish  habits  of  regularity.  A  regular  hour  must  be  settled 
upon  for  the  movements  of  the  bowels,  either  in  the  morning,  or  at 
night  before  going  to  bed.  Many  of  my  patients  find  the  hour  of 
bedtime  the  most  convenient,  especially  when  they  are  obliged  to 
resort  to  the  use  of  an  enema.  By  having  a  night  of  rest  afterwards, 
they  arc  spared  the  fatigue  which  many  experience  for  hours  after 


IMPORTANCE    OF    DETAILS.  117 

the  bowels  have  been  moved  in  the  mornhig.  I  have  also  met  with 
several  patients  who  only  slept  well  when  the  bowels  had  been  emptied 
just  before  going  to  bed. 

As  the  treatment  of  the  diseases  of  the  female  organs  of  genera- 
tion embraces,  in  some  form,  the  whole  field  of  the  practice  of  medi- 
cine, it  is  not  possible  to  do  more  than  to  offer  general  suggestions 
bearing  on  the  more  prominent  features.  For  the  successful  treat- 
ment of  these  diseases,  a  more  general  and  accurate  knowledge  is 
requisite  than  in  the  practice  of  any  other  branch  of  the  profession, 
since,  through  the  influence  of  the  s^'mpathetic  system,  as  we  have 
already  seen,  reflex  irritation  and  remote  functional  disturbances  are 
the  rule.  The  advocate  for  either  general  or  local  treatment  ex- 
clusively, or  he  who  neglects  to  give  the  proper  attention  to  both, 
does  not  possess  sufficient  practical  knowledge  to  extend  his  useful- 
ness beyond  the  range  of  an  empiric.  The  successful  physician  or 
surgeon  is  eminently  noted  for  his  personal  attention  to  details.  The 
most  profound  knowledge  adds  but  little  to  the  success  of  practice  if 
the  details  are  not  looked  to,  and  many  a  brilliant  operation  has  failed, 
and  even  entailed  disastrous  results  upon  the  patient,  for  the  want 
of  this  care  in  the  after-treatment.  The  purpose  of  this  chapter 
has  been,  and  the  object  in  view  throughout  the  work  will  be,  to  im- 
press the  reader  with  the  fact  that  success  in  the  treatment  of  the 
diseases  of  women  lies  wholly  in  attention  to  minute  details. 


118  LOCAL    TREATME]!^T. 


CHAPTER    YII. 

LOCAL  TREATMENT. 

The  condition  of  the  circulation  in  the  pelvis — Its  influence  on  local  disease — ^Must 
be  corrected  before  any  permanent  advance  can  be  made — The  effects  of  elec- 
tricity, cold  and  heat  in  exciting  contraction  of  vessels  through  reflex  action 
— Hot-water  vaginal  injections  ;  history  and  mode  of  use. 

It  has  been  stated  that  the  sympathetic  system  of  nerves  presides 
over  nutrition  and  the  organs  of  generation,  and  that  every  blood- 
vessel, to  the  minutest  capillary,  is  covered  by  a  network  of  nerve 
filaments  communicating  directly  with  the  different  ganglia.  When 
nutrition  is  impaired,  there  is  naturally  a  want  of  tone  in  the  blood- 
vessels. 

From  various  causes,  already  cited,  the  veins  of  the  pelvis  become 
gradually  over-stretched,  and  finally  lose  their  tone  to  such  an  extent 
that  almost  a  stasis  of  the  blood  takes  place  ;  at  least  to  such  a  degree 
that  we  may  compare  the  circulation  in  the  pelvis  to  that  existing  in 
a  marsh,  saturated  by  a  stream  which  is  of  about  equal  capacity  on 
entering  and  leaving  it,  but  maintaining  a  condition  approaching 
stagnation  between  the  two  points.  As  a  consequence  of  this  venous 
congestion  we  have  increased  size  and  weight  of  the  organs,  causing 
an  augmented  secretion.  Whenever  we  are  able  to  improve  the  gene- 
ral condition  of  a  patient  suffering  from  disease  of  the  organs  of  gener- 
ation, the  local  condition  improves  also,  but  only  to  a  limited  extent. 
Yet  this  increase  of  strength  renders  her  better  able  to  bear  the  con- 
stant drain  set  up  by  nature  in  efforts  to  relieve  the  congestion  by  an 
increase  of  secretion.  But  no  permanent  improvement  can  take  place, 
in  the  local  condition,  until  tone  has  been  restored  to  these  vessels, 
so  that  the  circulation  may  be  as  little  impeded  in  the  pelvis  as  in  any 
other  portion  of  the  body.  We  may  by  rest,  or  by  restoring  the  ute- 
rus to  its  proper  position,  lessen  its  size,  and  by  the  same  means, 
aided  by  local'applications,  at  length  heal  an  erosion,  as  well  as  lessen 
the  discharge  from  the  uterine  canal  and  vagina.  But  the  case  will 
relapise,  and  at  the  end  of  a  few  weeks  or  months  after  the  patient 
has  begun  to  exercise,  the  original  condition  will  have  been  repro- 


EFFECTS    OF    HOT    WATER.  119 

duced.  It  is  only  by  exciting  reflex  action  that  these  nerves,  accom- 
panying the  vessels,  will  cause  their  contraction,  and  with  increased 
action  on  their  part  the  necessary  tonicity  will  be  restored  by  unproved 
nutrition. 

"We  have  three  agents  for  exciting  this  reflex  action,  viz.,  electricity, 
cold,  and  heat. 

Electricity  exerts  a  decided  effect  during  the  time  of  the  passage  of 
the  current,  but  the  impression  is  too  transitory,  and  the  agent  is  only 
to  be  relied  upon  as  a  valuable  adjuvant. 

Cold  is  a  prompt  excitor  of  reflex  action,  by  which  the  vessels  con- 
tract, but  on  reaction  taking  place  the  parts  will  become  more  con- 
gested than  before,  with  both  the  arteries  and  veins  distended. 

Heat,  unless  at  a  temperature  which  would  destroy  the  parts,  does 
not  act  as  promptly  in  causing  this  contraction  as  either  electricity  or 
cold.  In  fact  its  immediate  effect  is  to  cause  relaxation,  and  to  in- 
crease the  congestion  of  the  parts  ;  but  if  its  application  be  prolonged, 
reaction  ensues,  and  contraction  takes  place  ;  in  other  words,  the  re- 
action from  heat  is  contraction.  The  capillaries  are  excited  to  in- 
creased action,  and  as  they  contract  from  the  stimulus  of  these  nerves, 
the  tonic  effect  extends  to  the  coats  of  the  larger  vessels,  their  calibre 
in  turn  becomes  lessened,  and  with  this  approach  to  healthy  action  the 
congestion  is  diminished.  The  popular  belief  is  that  heat  relaxes  and 
increases  the  congestion  of  the  parts,  and  such  indeed  is  the  case  at  first. 
But  a  hot  poultice  is  never  applied  Avith  the  object  of  increasing  the  con- 
gestion, but,  as  any  "  old  wife"  would  express  it,  to  draw  the  "  fire" 
or  inflammation  out ;  in  other  words  it  lessens  the  congestion  by  stimu- 
lating the  bloodvessels  to  contract.  That  such  is  the  effect,  from  the 
continued  use  of  a  poultice,  is  familiar  to  every  one,  and  is  shown  by 
the  blanched  and  shrivelled  appearance  of  the  tissues  after  its  removal. 
The  hands  and  arms  of  a  washer-woman  become  swollen  at  first,  from 
the  increased  flow  of  blood,  when  in  hot  water,  but  the  fact  is  quite  as 
familiar  that  they  afterwards  become  markedly  shrivelled. 

To  place  the  hands  in  cold  water  will  at  once  cause  the  skin  to 
shrivel,  as  the  vessels  are  stimulated  to  contract,  but  we  are  all  familiar 
with  the  fact  that  reaction  promptly  comes  on,  and  a  larger  quantity 
of  blood  returns  to  the  parts  than  was  driven  out ;  the  skin  does  not 
recover  its  natural  appearance  for  hours,  and  when  reaction  does  take 
place,  by  relaxation  of  the  vessels,  there  will  be  an  approach  to  con- 
gestion. The  immediate  effect  of  cold,  therefore,  is  contraction,  and 
with  reaction  comes  dilatation  ;  but  the  reverse  is  true  of  heat,  which 
causes  at  first  dilatation,  followed,  however,  by  contraction. 


120  LOCAL    TllEATMENT.  . 

With  these  practical  points  before  us,  we  resort  to  the  prolonged 
use  of  hot  water,  by  vaginal  injections,  to  gradually  bring  about  the 
required  contraction  and  tone  in  the  pelvic  vessels.  Whenever  in- 
flammation exists,  we  have  congestion  of  the  arterial  capillaries,  and 
when  it  subsides,  there  remains,  among  other  results,  the  condition 
erroneously  termed  chronic  inflammation  :  a  condition  essentially  the 
same  as  the  one  just  described,  attended  with  a  loss  of  tone  in  the 
vessels  and  an  obstructed  circulation,  but  it  is  a  misnomer,  since  it 
is  generally  found  where  no  previous  inflammation  has  existed.  The 
usual  seat  of  the  inflammation,  and  the  circumstances  under  which  it 
is  generally  found,  have  already  been  stated,  as  well  as  the  fact  that 
the  condition  we  have  chiefly  to  deal  with  is  the  direct  result  of  a 
loss  of  tone  in  the  venous  circulation  throughout  the  pelvis. 

The  use  of  hot  Avater  vaginal  injections  is  equally  beneficial  in  all 
those  conditions  which  constitute  the  various  forms  of  disease  in  the 
female  organs  of  generation,  and  which  are  amenable  to  any  treat- 
ment other  than  a  surgical  procedure  ;  and  equally  so,  whether  the 
congestion  be  venous  or  arterial.  This  remedy  is  not  to  be  considered 
a  "  cure-all,"  but  one  of  the  most  valuable  adjuvants,  under  all  circum- 
stances, to  other  means.  Yet,  so  beneficial  is  its  use,  except  in  dis- 
placements of  the  uterus,  that  I  believe  more  can  be  accomplished  in 
the  treatment  of  the  diseases  of  Avomen  by  this  agent,  and  a  carefully 
regulated  plan  of  general  treatment,  than  by  all  other  means  com- 
bined. 

If  a  vaginal  injection  has  been  properly  administered,  in  accordance 
with  the  directions  given  on  page  51,  the  mucous  membrane  will  be 
found  blanched  in  appearance,  and  the  usual  size  of  the  canal  lessened 
in  calibre,  as  after  the  use  of  a  strong  astringent  injection.  As  the 
patient  lies  on  the  back,  with  her  hips  elevated,  the  action  of  gravity 
will  be  brought  into  play,  by  which  the  veins  will  be  rapidly  emptied, 
sufficiently  to  relieve  the  over-distension.  When  in  this  position  also, 
the  vagina  will  become  fully  distended  by  the  weight  of  water  and 
kept  so,  since  only  the  surplus  amount  can  run  off  into  the  bed-pan 
beneath..  The  hot  Avater  Avill  then  be  in  contact  Avith  every  portion 
of  the  mucous  membrane  under  Avhich  the  capillaries  lie.  The  vessels 
going  to  and  from  the  cervix  and  body  of  the  uterus  pass  along  the 
sulcus  on  each  side  of  the  vagina,  and  their  branches  inclose  the 
vagina  in  a  complete  netAvork.  The  vessels  of  the  fundus,  through 
the  veins  of  Avhich  the  blood  flows  to  the  liver,  and  back  into  thq 
general  circulation,  communicate  freely,  by  anastomosis,  Avith  the 
vessels  distributed  to  the  body  and  cervix  below.     If,  then,  Ave  are 


HOT    AVATER    INJECTIONS.  121 

able  to  cause  the  vessels  of  the  va;2:uia  to  contract,  throusrh  the  stimu- 
lus  of  the  hot  water,  we  can,  directly,  or  indirectly,  influence  the 
■whole  pelvic  circulation.  It  is  most  important  to  appreciate  the 
necessity  for  elevating  the  hips,  by  Avhich  plan  so  large  a  portion  of 
the  venous  blood  becomes  drawn  off  by  gravitation.  If  the  stimulus 
of  the  hot  water  is  then  applied,  so  as  to  cause  the  vessels  to  con- 
tract still  more,  we  will,  for  a  time  at  least,  have  the  pelvic  circula- 
tion reduced  almost  to  a  natural  condition.  In  order  to  allow  the 
condition  of  contraction  to  be  as  prolonged  as  possible,  I  generally 
direct  the  injection  to  be  given  at  night,  in  bed,  just  as  the  patient  is 
ready  to  retire.  Thus,  by  constantly  causing  these  vessels  to  con- 
tract, and  by  resorting  to  every  other  means  of  lessening  the  supply 
of  blood  in  the  pelvis,  we  will  succeed  eventually  in  securing  a  proper 
vascular  tone.  No  plan  of  treatment  could  be  more  rational,  or  appeal 
more  forcibly  to  the  good  judgment  of  every  one.  But,  unfortunately, 
from  a  neglect  of  details,  it  is  rare  that  the  slightest  benefit  is  derived 
from  the  use  of  these  injections,  although  so  many  years  have  elapsed 
since  the  profession  has  been  fully  informed  as  to  their  mode  of  action. 
For  fifteen  years  at  least,  I  have  been  experimenting  by  different 
methods  in  the  use  of  hot  water,  and  have  had  during  that  time  as 
large  a  number  of  cases  as  would  be  likely  to  be  at  the  service  of  any 
one,  and  I  have  arrived  at  the  conclusion  that  it  is  an  impossibility  for 
a  patient  to  properly  give  these  injections  to  herself,  so  as  to  derive 
their  full  benefit.  Not  the  slightest  advantage  is  received  from  them 
when  administered  with  the  patient  in  the  upright  position,  or,  as  is 
the  usual  method,  while  seated  over  a  bidet,  for,  given  thus,  the  water 
does  not  dilate  the  passage,  but  returns  along  the  nozzle  of  the  syringe. 
I  have  found  that  the  best  mode  of  all  is  to  have  the  injections  given 
while  the  patient  is  placed  on  her  knees  and  elbows  or  chest.  In  this 
position  we  have  the  assistance  both  of  gravity  and  the  pressure  of  the 
atmosphere  to  empty  the  pelvic  veins,  while  the  water  is  able  to  act  on 
a  much  larger  surface  of  the  vagina  than  it  is  when  the  patient  is  in 
any  other  position.  But  this  position  is  a  difficult  one  to  assume, 
since  those  who  are  in  the  greatest  need  of  hot  water  have  not  the 
strength  to  remain  in  it  long  enough  to  accomplish  the  purpose  ;  and 
considerable  difficulty  is  also  experienced  in  keeping  the  patient  dry. 
This  latter  difficulty,  however,  can  in  a  measure  be  overcome  by  using 
a  funnel-shaped  receptacle,  with  an  India-rubber  tube  attached  to 
the  smaller  end,  the  two  sides  being  indented  sufficiently  to  enable 
the  patient  to  retain  it  in  place  by  keeping  the  thighs  together.  I 
have  also  used  an  inclined  plane  to  elevate  the  hips  ;  it  should  come 


122  LOCAL    TREATMENT. 

up  between  the  legs,  and  have  a  hole  cut  large  enough  for  the  but- 
tocks, so  that  the  water  may  flow  into  a  receptacle  below.  These 
methods,  or  any  other  procedure  which  the  ingenuity  of  the  physician 
may  suggest,  can  be  employed,  so  long  as  the  action  of  gravity  is 
brought  into  play,  and  the  vagina  can  be  dilated  by  the  water.  But 
for  the  largest  number  of  cases,  the  position  on  the  back,  with  a  bed- 
pan to  elevate  the  hips,  will  be  found  the  most  convenient.  Few  women 
are  so  situated  as  to  be  unable  to  get  some  one  to  administer  the  injec- 
tions properly,  and  the  inconvenience  of  soliciting  aid  is  a  trifling  one 
considering  the  benefit  to  be  derived  from  it,  since  experience  has 
shown  that,  unless  the  details  can  be  carried  out  fully,  the  process 
only  involves  a  waste  of  time,  and  a  tax  on  the  strength  of  the  patient. 

The  temperature  and  quantity  of  water  are  to  be  varied  according 
to  circumstances.  When  treating  the  early  stages  of  inflammation, 
it  is  necessary  that  the  temperature  should  be  elevated  rapidly  from 
that  of  blood-heat  to  110°,  or  to  as  high  a  degree  as  can  be  borne  by 
the  patient,  and  that  the  injection  should  be  often  repeated.  For 
ordinary  use,  a  gallon  of  water  two  or  three  degrees  above  blood- 
heat  is  generally  sufficient,  but  the  temperature  must  be  maintained 
at  the  highest  point  by  the  addition  of  hot  water  from  time  to  time. 
The  hour  of  bed-time  is  generally  the  best  in  which  to  seek  for  the 
beneficial  effects  of  hot  water  on  the  reflex  system,  in  allaying  the 
local  irritation ;  for  prolonged  vaginal  injection,  at  a  high  tempera- 
ture, will  often,  when  given  by  an  experienced  hand,  act  with  more 
promptness  than  an  anodyne,  in  allaying  the  nervousness  and  sleep- 
lessness of  an  hysterical  Avoman.  I  have  frequently  known  a  patient, 
after  being  well  rubbed,  and  having  received  an  injection,  to  fall  asleep 
before  the  nurse  had  completed  the  process,  and  to  be  so  overcome 
with  drowsiness  as  to  be  but  little  disturbed  on  removing  the  bed-pan. 

In  rare  instances,  and  from  a  condition  I  am  unable  to  explain, 
cases  are  met  with  where  a  sense  of  weight  and  an  uncomfortable 
feeling  are  experienced  about  the  pelvis  after  an  injection  of  water  at 
the  usual  temperature.  In  some  instances  so  much  disturbance  re- 
sulted, that  occasionally  I  was  obliged  to  abandon  its  use.  But  I 
have  long  since  ascertained  that  the  injection  is  well  borne  at  a  lower 
temperature,  generally  about  95°,  and  that  after  a  week  or  two  the 
temperature  can  be  gradually  increased. 

This  ".cooking  process,"  as  it  has  been  facetiously  termed,  is  ren- 
dered easier  by  the  use  of  ivory,  or  some  other  non-conducting  mate- 
rial, for  the  nozzle  of  the  syringe,  since  the  patient  suffers  more 
discomfort  from  the  heated  metal  surface  of  the  ordinary  nozzle  com- 


HOT    WATER    TO    ARREST    HEMORRHAGE.  123 

ing  in  contact  with  the  outlet  of  the  vagina  than  from  any  degree  of 
heat  in  the  water  which  it  is  advisable  to  employ. 

To  the  injection  (generally  to  the  last  pint)  may  be  added,  glyce- 
rine, chlorate  of  potash,  chloride  of  sodium,  carbonate  of  soda,  borax, 
Castile  soap,  sulphate  of  copper,  muriate  of  ammonia,  brewer's  yeast, 
permanganate  of  potassa,  carbolic  acid,  or  any  other  remedy  which 
may  seem  to  be  indicated. 

As  the  patient  improves  in  health  the  quantity  of  water  for  the  in- 
jections may  be  lessened,  and  the  temperature  gradually  lowered  to 
about  GO^,  and  then  discontinued.  But  for  some  months  it  Avould  be 
prudent  for  a  few  days  after  each  period  to  resume  the  injections 
at  a  deo-ree  or  two  above  blood  heat,  and  to  have  recourse  to  them 
whenever  their  use  should  seem  indicated,  to  counteract  the  effect  of 
some  imprudence. 

In  the  summer  or  early  autumn  of  1859,  during  the  temporary 
absence  of  Dr.  Sims,  I  was  operating  at  the  Woman's  Hospital  to 
close  a  vesico-vaginal  fistula,  where  it  was  necessary  to  free  the  tissues 
behind  the  ramus.  The  progress  of  the  operation  had  been  greatly 
delayed  in  consequence  of  oozing  of  blood,  which  I  had  checked  by 
pressure  and  pieces  of  ice,  but,  on  resuming  the  operation,  in  a  few 
moments  reaction  would  take  place,  and  the  bleeding  became  as  great 
as  before.  The  late  Dr.  Pitcher,  of  Detroit,  was  present,  and  sug- 
gested that  I  should  dip  a  sponge  probang  into  hot  water  and  apply  it 
several  times  to  the  surface  ;  I  did  so,  and,  to  my  surprise,  the  bleed- 
ing was  promptly  arrested.  His  explanation  was,  that,  as  the  clot 
formed  in  the  mouth  of  a  vessel  dilated  by  the  heat,  it  would  be  so 
firmly  held  by  the  contraction  of  the  vessel,  when  reaction  took  place, 
that  secondary  hemorrhage  could  not  occur.  He  then  stated  to  me 
he  had  been  in  the  habit,  for  many  years,  when  operating,  of  apply- 
ing to  a  bleeding  surface  sponges  taken  from  water  as  hot  as  could 
be  borne. 

From  the  earliest  days  of  my  study  in  this  branch  of  surgery  I 
have  been  skeptical  as  to  the  part  inflammation  was  supposed  to  play 
in  the  diseases  of  women.  Since  I  first  had  an  opportunity  to  form 
an  opinion,  my  views  have  been  essentially  what  they  are  to-day,  and 
I  have  taught  the  same  for  years  at  the  Woman's  Hospital,  as  is  well 
known.  In  fact,  my  views  w^ere  formed  at  so  early  a  date,  that  I 
have  never  applied  a  leech  in  my  life  to  the  uterus,  or  scarified  the 
cervix  with  the  view  of  reducing  inflammation.  Dr.  Pitcher's  sug- 
gestion made  a  deep  impression  on  me,  but  it  required  years  to 
appreciate  its  full  import.    But,  having  once  realized  the  influence  of 


124  LOCAL    TREATMENT. 

heat  as  an  excitor  of  reflex  action,  it  became  the  means  of  clearino; 
up  for  me  many  points  in  pathology,  and  hot  water  has  proved  a  most 
important  agent  in  my  hands  in  the  treatment  of  the  diseases  of 
women.  At  the  time  my  attention  was  first  drawn  to  this  subject  the 
universal  practice  was  the  use  of  vaginal  injections  of  cold,  and  even 
iced-water.  I  began  to  use  tepid,  and  then  warm  water  in  my  private 
practice,  but  at  that  time  my  opportunities  for  personal  observation 
were  limited.  However,  from  September,  1862,  when  I  Avas  placed 
in  charge  of  the  Woman's  Hospital,  to  the  present  time,  nearly  every 
patient  coming  under  my  care  in  this  institution,  as  in  private  practice, 
has  been  treated  by  this  method,  the  quantity  and  temperature  of 
the  water  being- varied  according  to  the  peculiarities  of  each  case. 

Yet,  I  do  not  claim  to  have  been  the  first  person  under  whose  di- 
rection a  vagina  was  ever  washed  out  with  warm  water ;  but  I  do 
claim  to  have  been  the  first  to  use  the  agent  in  a  systematic  manner, 
for  the  treatment  of  the  diseases  of  women,  and  to  have  done  so  with 
a  definite  purpose,  in  keeping  with  what  I  considered  to  be  sound 
pathology. 

In  every  theory  of  inflammation  congestion  is,  of  course,  considered 
a  prerequisite  stage,  but  the  congestion  is  commonly  supposed  to  be 
arterial,  and  all  plans  of  treatment  are  directed  to  overcome  this 
condition. 

So  far  as  I  know  I  may  justly  claim  to  have  been  the  first  to  teach, 
that  congestion  of  the  pelvic  contents,  under  ordinary  conditions,  is 
venous,  and  due  to  loss  of  tone  in  the  vessels  from  impaired  nutrition. 
This  naturally  led  me  to  elevate  the  hips,  so  that,  by  the  action  of 
gravity,  the  congestion  might  be  lessened,  and  then  I  applied  hot  Avater 
to  bring  about  a  further  contraction  of  the  vessels  by  reflex  action, 
which  would  lead  gradually  to  a  permanent  restoration  of  their  tone 
and  calibre. 


PROPER    POSITION    OF    THE    UTERUS.  125 


CHAPTER    VIII. 

PRINCIPLES  OF  TREATMENT  CONTINUED:  DISPLACEMENTS,  PELVIC 
CIRCULATION,  LINING  MEMBRANE  OF  THE  UTERUS,  APPLICATIONS 
TO  THE  UTERINE  CANAL. 

Proper  position  of  the  uterus — The  essential  principle  is  to  remove  obstruction  to 
the  uterine  circulation — Positions  either  too  low  or  too  high  are  objectionable — 
Campbell's  pneumatic  repositor — Chronic  inflammation  and  'ulceration  do  not 
exist — Remedies  :  Nitrate  of  silver — Carbolic  acid — Grlycerine — Iodine — Use  of 
applicator — Powdered  substances — Pith  of  corn  stalk — Sponge-tents  to  reduce 
size  of  uterus — Injections  of  Churchiirs  tincture  of  iodine  into  uterine  cavity- 
Hot  water  in  the  uterine  cavity — Blisters  to  the  cervix — Hyperesthesia  is  not 
inflammation. 

If  the  views  which  have  been  advanced  as  to  the  condition  of  the 
pelvic  circulation  attending  diseases  of  long  standing  in  the  female 
organs  of  generation  be  correct,  it  becomes  evident  that  it  is  of  para- 
mount importance  that  the  uterus  should  occupy  a  position  where  its 
circulation  shall  be  without  obstruction.  When  the  uterus  is  displaced 
backward,  forward,  or  to  either  side,  the  displacement  is  generally 
recognized,  and  an  attempt  is  made  to  maintain  it  by  some  mechanical 
means  in  the  upright  position.  But  the  true  principle  for  correcting 
the  various  displacements  is  seldom  fully  appreciated.  In  general 
terms,  it  may  be  said  that  there  is  no  common  standard  by  which  to 
determine  the  proper  position  for  the  uterus  in  all  women,  but  that 
in  each  individual  there  is  a  point,  or  plane,  in  the  pelvis  which  the 
uterus  should  occupy  when  she  is  in  a  state  of  health  and  not  preg- 
nant. 

We  are  all  familiar  with  the  fact  that  the  uterus  is  frequently  found 
extremely  anteverted,  yet  the  female  will  be  in  perfect  health  and 
suiferincr  not  the  slightest  inconvenience.  The  same  is  true  of  retro- 
version,  although  this  may  entail  sterility,  and  the  position,  from 
mechanical  causes,  may  render  her  more  liable  to  some  complication  ; 
yet,  until  this  does  occur,  she  may  pass  through  life  unconscious  of 
its  mal-position.  Of  course,  it  is  advisable  to  correct  a  retroversion  if 
possible,  but  I  hold  that  it  is  not  so  much  the  position  which  is  to  be 
corrected,  as  it  is  the  obstruction  to  the  circulation  in  the  organ  which 
is  to  be  removed.     The  uterus  may  occupy  a  position  in  the  axis  of 


126  PRINCIPLES    OF    TREATMEXT. 

the  pelvis  which  might  be  faultless,  by  comparison  with  any  accepted 
standard,  yet  the  disturbance  may  be  as  marked  as  in  an  extreme 
case  of  version,  should  the  organ  occupy  a  lower  plane  in  the  pelvis 
than  is  normal.  As  soon  as  the  uterus  settles  to  a  plane  below  the 
health  line,  as  it  may  be  termed,  the  tissues  will  be  put  on  the  stretch 
sufficiently  to  compress  or  obstruct  the  veins,  while  the  arteries 
will  not  be  affected.  This  is  just  the  condition  in  pregnancy  when, 
from  the  settling  down  of  the  uterus,  the  veins  become  distended  to 
an  enormous  size.  As  the  organ  grows,  the  additional  weight  con- 
tinues to  add  to  the  difficulty,  by  inducing  congestive  hypertrophy. 
With  pregnancy,  the  obstruction  to  the  circulation  is  relieved  a  short 
time  after  quickening,  and  the  vessels  are  able  to  regain  their  natural 
size,  but  towards  the  close  of  gestation  the  venous  circulation  is  again 
impeded  by  the  upward  traction. 

While  writing,  I  recall  the  history  of  a  case  sent  me  by  Dr.  Woolsey 
Johnson,  of  this  city,  which  shows  the  importance  of  recognizing  the 
existence  of  this  health  line.  I  mention  the  doctor's  name  in  con- 
nection with  the  case,  from  the  fact  that  he  watched  the  progress  of 
the  treatment  closely,  and  was  familiar  with  all  the  details.  When  I 
made  my  first  examination,  nearly  every  portion  of  the  vagina,  as 
well  as  the  cervix,  Avas  extremely  sensitive  on  pressure,  and  the  pulsa- 
tion of  large  vessels  could  be  felt  at  different  points.  This  condition 
had  existed  to  some  extent  for  several  years,  having  followed  a  severe 
labor  with  her  first  child,  but  had  been  much  woi'se  after  wearing  a 
pessary,  which  it  had  been  thought  necessary  to  introduce.  The  uterus 
was  about  four  inches  deep,  and  very  much  anteverted.  She  of  course 
suffered  with  backache,  difficulty  in  standing  or  walking,  and  from 
leucorrhoea.  I  recognized  the  importance  of  lifting  the  uterus  in  the 
pelvis,  but  with  the  sensitive  condition  of  the  vagina,  a  pessary  at  the 
time  could  not  have  been  tolerated.  To  a  certain  point,  she  improved 
rapidly  from  the  use  of  hot  water  injections  and  the  application  of 
iodine  over  the  vaginal  surface.  During  a  subsequent  examination, 
the  patient  lying  on  the  back,  I  lifted  the  uterus  gently  on  the  end  of 
my  finger,  to  judge  whether  its  mobility  had  been  lessened  by  the  re- 
mains of  an  old  cellulitis,  which -had  occurred  behind  and  to  the  left  of 
the  organ.  At  a  certain  point  she  remarked  that  the  backache  was 
relieved  ;  the  uterus  was  then  lifted  higher,  but  with  a  return  and 
increase  of  the  pain  ;  it  was  then  allowed  to  settle  again,  with  relief, 
and  a  return  of  the  pain  was  experienced  as  the  organ  reached  its 
usual  low  position.     I  then  slowly  and  gently  lifted  the  uterus  again 


NORMAL    POSITION    OF    THE    UTERUS.  127 

to  a  plane  in  the  pelvis  at  which  the  pain  ceased.  At  this  point  I  held 
the  organ  for  some  ten  minutes,  giving  her  great  relief,  and  at  the 
end  of  that  time  the  pulsation  in  the  arteries  had  ceased,  and  the 
quantity  of  hlood  in  the  veins  diminished.  This  was  done  day  after 
day,  until  she  was  ahle  to  go  for  a  longer  interval  hefore  returning 
pain  and  discomfort  rendered  it  necessary  to  be  repeated.  The  uterus 
decreased  in  size,  the  tenderness  in  the  vagina  became  less,  and  at 
length  she  was  able  to  wear,  with  comfort,  a  pessary,  which  held 
the  uterus  in  its  proper  place  in  the  pelvis.  Notwithstanding  that 
she  suffered  from  two  attacks  of  pneumonia  and  one  of  dysentery, 
within  a  year,  and  that  her  general  health  was  much  impaired  before 
she  came  under  my  charge,  she  is  now  essentially  well  of  her  local 
difficulty.  The  treatment  consisted  in  the  injection  of  hot  water, 
properly  administered,  daily,  and  in  her  placing  herself  on  her  knees, 
and  letting  the  air  pass  into  the  vagina  to  lift  the  uterus  whenever  she 
felt  the  necessity  for  doing  so.  Dr.  Johnson,  at  the  same  time,  looked 
after  her  general  health.  The  uterus  was  lifted  into  its  proper  place, 
and  a  pessary  Avas  fitted,  which  she  continues  to  wear ;  iodine  was 
applied  occasionally  to  the  vaginal  walls,  and  pledgets  of  cotton  satu- 
rated with  glycerine  were  frequently  placed  in  the  vagina.  No  appli- 
cation of  any  description  was  made  to  the  uterine  canal,  for  fear  of 
lighting  up  the  old  cellulitis. 

The  practical  lesson  to  be  draAvn  from  this  case  is  that  the  cel- 
lulitis was,  in  all  probability,  caused  by  a  pessary  which  lifted  the 
uterus  too  high  in  the  pelvis,  above  its  natural  position,  by  which  the 
connective  tissue  was  put  on  the  stretch.  Involution  of  the  uterus 
had  not  been  perfect,  and  from  the  obstruction  to  the  circulation  due  to 
the  cellulitis,  the  size  of  the  uterus  had  been  increased  so  as  in  turn 
to  be  an  additional  source  of  irritation.  But  the  most  important  fea- 
ture of  the  case  is  one  which  has  been  already  referred  to,  and  will 
again  be  considered  at  length.  The  greater  poi'tion  of  the  weight  of 
the  uterus  was  suspended  from  the  shortened  broad  ligament  which 
had  been  the  seat  of  a  previous  cellulitis,  so  that  the  circulation  through 
both  the  arteries  and  veins  was  obstructed.  The  arterial  congestion 
rendered  the  parts  more  sensitive,  and  brought  about  a  condition  which 
made  her  liable,  on  the  slightest  provocation,  to  a  fresh  attack  of  cel- 
lulitis, while  the  venous  obstruction  increased  the  hypertrophy,  and 
caused  the  profuse  leucorrhoea.  As  soon  as  the  uterus  was  lifted  in 
the  pelvis  to  a  point  where  the  drag  on  the  tissues,  which  had  been 
previously  inflamed,  ceased,  the  circulation  at  once  became  restored, 
and  the  pain  was  relieved. 


128  PRINCIPLES    OF    TREATMENT. 

This  case  illustrates  an  eifect  resulting  from  one  of  the  commonest 
errors  committed  in  practice — that  of  lifting  the  uterus  too  high  in 
the  pelvis.  Many  an  expert  succeeds  in  fitting  an  instrument  which 
will  prevent  the  uterus  from  becoming  again  retroverted,  but  often 
fails  to  appreciate  the  plane  or  height  at  which  the  uterus  should  be 
held  in  the  pelvis. 

Let  the  line  A,  B  (Fig.  40)  represent  the  line  or  plane  which  the 
uterus  occupies  in  the  individual  when  in  a  state  of  health,  and  at  a 

Fi-.  40. 


M 


->B. 


C 

The  normal  or  health  line. 

point  where  the  blood  flows  to  and  fro  without  obstruction.  By  some 
accident  the  uterus  becomes  displaced,  and  has  its  circulation  so  ob- 
structed that  by  increased  weight  it  at  length  prolapses,  or  sags,  to 
the  point  C,  and  causes  so  much  disturbance  that  the  patient  will  seek 
advice.  The  general  idea  is  to  correct  the  difficulty  at  once  by  elevating 
the  uterus  well  in  the  pelvis  to  the  point  D,  it  being  a  natural  impulse 
to  correct  every  extreme  by  going  remote  from  it.  But  just  in  pro- 
portion as  the  uterus  is  lifted  above  the  health  line  A  B,  we  will  have 
the  same  effect  produced  as  existed  when  it  was  in  a  state  of  prolapse, 
below  the  line.  This  is  the  reason  why,  after  fitting  an  instrument, 
the  uterus  is  so  often  found  to  have  increased  instead  of  being  dimin- 
ished in  size.  Another  result'will  also  be  observed,  as  an  effect  of 
obstructing  the  circulation,  namely  that  the  leucorrhoea  and  discharge 
from  the  uterine  canal  Avill  increase,  and  an  erosion  soon  form  on  the 
cervix  where  it  had  not  previously  existed. 

We  have  already  considered  the  action  of  gravity  called  into  play 
by  elevating  the  hips,  and  the  influence  excited  by  the  presence  of 


EFFECT    OF    ATMOSPHERIC    PRESSURE    ON    THE    VAGIXA.      129 

the  atmosphere,  in  connection  with  gravity,  when  the  patient  is  placed 
on  the  knees  and  elbows  for  the  purpose  of  receiving  a  vaginal  injec- 
tion. I  have  been  familiar  with  the  action  of  atmospheric  pressure 
on  the  vaginal  wall  since  1854,  when  I  first  heard  Dr.  Sims  describe, 
in  a  public  lecture,  the  use  of  his  speculum.  In  the  AVoman's  Hos- 
pital, from,  the  very  first,  we  were  accustomed,  under  certain  circum- 
stances, to  place  cases  of  vesico-vaginal  fistula  on  the  knees  and  elbows 
to  secure  greater  facility  in  making  the  examination  and  in  operatino-. 
For  the  past  ten  years  I  have  fully  recognized  the  advantages  of 
this  position  in  the  treatment  of  uterine  displacements,  and  have  both 
practised  and  taught  its  use  during  that  time.  "When  treating  spe- 
cially of  the  subject  of  retroversion,  this  matter  will  be  fully  considered 
in  connection  with  a  case  which  I  reduced  by  this  method  in  1867. 

Some  years  ago  I  wrote  :^  "It  is  well,  when  there  is  simply  a  pro- 
lapse, to  remove  the  instrument  frequently  while  the  patient  is  quiet, 
so  that  the  circulation  may  not  be  impaired."  I  often  give  my  pa- 
tients instructions  at  night  to  assume  the  position  on  the  knees  and 
elbows,  after  taking  out  the  instrument,  and  to  open  with  the  fingers 
the  outlet  of  the  vagina  while  in  this  position,  so  that  the  uterus  may  be 
carried  well  up  into  the  pelvis  by  atmospheric  pressure.  If  the  patient 
is  all  ready  for  her  bed,  a  large  portion  of  the  air  will  be  retained  if 
she  carefully  assumes  the  horizontal  position.  I  have,  however,  not  con- 
fined this  method  to  cases  of  prolapse,  but  frequently  advise  a  resort 
to  it  when  the  patient  is  fatigued  from  exercise,  and  when  wakeful  at 
night. 

This  mode  of  treatment  is  apparently  in  contradiction  to  the  state- 
ment previously  made  as  to  the  effect  obtained  from  lifting  the  uterus 
too  high  in  the  pelvis  with  a  pessary.  But  such  is  not  the  case,  since 
the  vessels  are  to  a  great  extent  emptied  by  the  pressure  of  the  atmos- 
phere and  by  gravity.  The  pressure  also  is  uniform  and  not  confined 
to  a  portion  of  the  tissues,  as  would  be  the  case  with  an  instrument. 
But  more  particularly  from  the  natural  elasticity  of  the  pelvic  tissues 
there  could  be  no  persistent  traction  exerted  on  the  veins,  to  compress 
them,  since  this  same  elasticity  would  soon  establish  an  equilibrium 
by  expelling  a  sufficient  quantity  of  air  from  the  vagina. 

The  chief  obstacle  I  met  with  formerly,  in  carrying  out  the  plan,  was 
the  difficulty  frequently  found  in  admitting  air  to  the  vagina.  This 
was  experienced  by  almost  all  women  who  had  not  borne  children,  and 

'  Prolapsus   Uteri,  its   Chief  Causes  and    Treatment,  N.  Y.  Medical    Record    of 
April  15,  1871  ;  and  Transactions  of  the  N.  Y.  State  Medical  Society  for  1871. 
9 


130  PRINCIPLES    OF    TREATMENT. 

with  the  unmarried  or  stout  women,  it  was  often  impossible  to  0)3en  the 
vaginal  outlet  by  means  of  the  fingers. 

This  difficulty  has  now  been  entirely  overcome  by  an  instrument 
(Fig.  41)  devised  by  Prof.  Henry  F.  Campbell,  of  Augusta,  Ga. 
It  consists  of  a  glass  tube  opened  at  both  ends,  slightly  bent,  with  a 
rounded  extremity,  which  admits  of  easy  introduction  of  both  the  in- 
strument and  air  into  the  vagina.  The  device  is  so  simple  a  one  that 
it  is  remarkable  its  use  had  not  suggested  itself,  since  I  was  familiar 
with  Dr.  Sims's  former  practice  of  leaving  a  tube  in  the  vagina,  after  an 

FiR.  41. 


CampbeU's  "pneiimatic  repositor  " 

examination,  for  the  free  passage  of  air,  as  the  patient  changed  her 
position,  as  otherwise  it  might  escape  with  a  noise  as  if  from  the  anus. 
I  use  the  term  "  on  the  knees  and  elbows"  as  the  one  commonly 
employed  in  the  Woman's  Hospital,  but  it  is  in  effect  the  same  de- 
scribed by  Dr.  Campbell  as  the  "  genu-pectoral  position,"  since  the 
practice  has  always  been  to  bring  the  out-spread  elbows  as  well  as  the 
chest  and  side  of  the  face  in  contact  with  the  table  at  the  same  time. 
We  are  now  to  consider  a  portion  of  the  subject  in  regard  to  which 
the  opinions  held  are  so  dissimilar,  that  there  exists  no  foundation  on 
which  a  conservative  practice  could  be  based  in  keeping  with  both 
extremes. 

If  the  so-called  ulceration  of  the  cervix  be  accepted  as  a  cause  and 
not  an  effect,  the  use  of  caustic  applications  is  a  consistent  practice, 
and  should  be  persevered  in  until  the  surface  has  been  healed. 

But  if  it  be  held  that  the  increased  secretion  is  simply  an  attempt 
of  nature  to  relieve  an  obstructed  venous  circulation,  and  that  the 
erosion  is  a  surface  from  which  the  epithelium  has  been  washed  away 
by  the  discharge  constantly  flowing  over  it,  then  such  a  course  of 
treatment  is  to  be  deemed  not  only  irrational  but  most  hurtful. 

A  whole  generation  of  physicians  has  been  misled  by  the  delusion 
of  chronic  inflammatio7i  and  ulceratioii  of  the  uterus,  conditions  which 
no  one  has  yet  been  able  to  demonstrate  on  the  dead  body. 

When  an  erosion  has  been  healed  by  caustic  applications  the  health 
of  the  woman  improves  rapidly,  since,  for  the  time,  a  great  leak  has 
been  stopped,  by  which  she  was  constantly  pouring  out  her  life-blood 


APPLICATIONS  TO  THE  OS  UTEKI.  131 

in  the  form  of  leucorrhceal  discharge.  But,  as  the  primary  cause 
is  not  removed,  the  erosion  must  return  again  and  again,  until  at 
length,  if  the  treatment  be  continued,  every  mucous  follicle  will  have 
been  destroyed,  and  no  further  discharge  can  take  place  ;  but  the  hy- 
pertrophy of  the  uterus  and  the  abnormal  condition  of  the  pelvic  cir- 
culation will  remain. '  If  the  application  be  strong  enough  to  produce 
a  slough,  then,  of  course,  the  mucous  follicles  will  be  destroyed  ;  but 
even  if  milder  means,  as  the  use  of  the  nitrate  of  silver,  be  persevered 
in  long  enough  to  heal  the  surface,  the  damage  will  be  f[uite  as  great, 
since  the  tissues  will  have  been  rendered  sufficiently  dense  to  cause 
atrophy  of  these  follicles,  and  after  either  mode  of  treatment  the 
tissues  become  essentially  cicatricial  in  character. 

The  subsequent  effect  of  such  applications  to  the  cervix,  is  more 
marked  than  when  made  to  the  canal  above  the  internal  os.  The 
cervix  is  covered,  and  its  canal  lined  by  a  highly  organized  and  per- 
fectly formed  mucous  membrane,  so  that  if  its  vitality  is  impaired, 
reflex  symptoms  of  irritation  are  made  most  manifest,  with  a  train  of 
symptoms  due  to  contraction  of  the  os  and  canal.  From  the  observa- 
tions of  recent  writers  it  is  a  questionable  point  if  a  true  mucous  mem- 
brane, or  any  lining  membrane  at  all,  exists  above  the  internal  os,  for 
what  seems  to  be  a  membrane  may  simply  be  an  outgrowth  from  the  mus- 
cular tissue  which  is  constantly  renewed.  It  is,  therefore,  irrational 
to  make  a  caustic  application  to  a  surface  which  cannot  long  exist  in 
a  state  of  disease,  independent  of  the  tissues  beneath,  and  we  cannot 
hope  to  arrest  a  discharge  until  the  whole  surface  has  been  seared 
over.  As  the  profession  has  for  years  been  familiar  with  the  after- 
effects of  the  cautery  and  caustics  on  mucous  membranes  in  other  parts 
of  the  body,  it  is  remarkable  that  their  use  should  still  be  continued 
in  the  treatment  of  the  diseases  of  the  female  organs  of  generation. 
Yet  conscientious  men  of  our  day,  after  the  use  of  the  cautery  or 
caustics,  will  leave  a  surface  on  the  vagina  or  cervix  to  heal  by  granu- 
lation, and  will  deny  that  the  surface  thus  formed  is  cicatricial,  or 
that  it  ever  contracts  ;  and  I  have  no  reason  to  doubt  that  they  think 
so,  but  I  do  impugn  the  accuracy  of  their  observation,  and  the  wisdom 
of  their  measures. 

When  the  surface  of  the  uterine  canal  has  become  covered  with 
granulations  or  ve2;etations,  the  actual  caviterv  and  the  strongest  mine- 
ral  acids  may  often  be  applied  Avith  impunity,  and  without  injury  to 
the  deeper  tissues,  since  they  are  thus  protected  ;  yet  the  practice, 
as  we  shall  see  hereafter,  except  for  the  treatment  of  malignant  dis- 
ease, is  unnecessary,  and  to  be  avoided. 


132  PRINCIPLES    OF    TREATMENT. 

We  have  no  means  of  judging  as  to  the  full  extent  of  disease  with- 
in the  uterine  canal,  or,  Avith  accuracy,  as  to  its  locality,  when  situated 
beyond  the  range  of  our  vision.  The  facility  for  locating  its  limit 
exclusively  to  the  cervix,  body,  or  fundus,  rests  only  in  the  brain  of 
the  theorist,  and  has  no  existence  in  pi-actice,  yet,  in  any  case,  it  will 
be  but  a  question  of  time  before  the  whole  canal  becomes  equally  in- 
volved. From  our  knowledge  of  the  character  of  the  lining  mem- 
brane of  the  cervix,  we  are  often  warranted  in  inferring  that  the 
cervical  portion,  near  the  internal  os,  is  involved  when  the  secretion  is 
profuse,  clear,  and  gleety,  and  that,  when  it  is  less  in  quantity  and 
consistence,  the  morbid  process  is  located  nearer  the  fundus.  Expe- 
rience also  indicates  that,  Avhen  the  discharge  is  profuse,  and  there  is 
but  little  enlargement  of  the  uterus,  the  disease  is  located  chiefly 
within  the  cervix,  and  will  probably  readily  yield  to  treatment.  While, 
if  the  uterus  is  enlarged,  and  menstruation  disturbed,  without  refer- 
ence to  the  character  of  the  discharge,  the  case  will  prove  a  more 
tedious  one  since  the  whole  organ  has  become  involved. 

Our  remedies  for  internal  use  should,  therefore,  be  of  a  character 
innocuous  to  healthy  tissue,  as  we  cannot  limit  their  action  to  the 
diseased  surface  exclusively.  Since  we  cannot  direct  our  remedies 
with  accuracy  within  the  uterine  canal,  or  watch  their  immediate  effect 
by  the  aid  of  the  eye,  our  practice  must  necessarily  be  somewhat 
empirical.  We  Avill  often  fail  in  obtaining  the  same  result  fi'om  a 
remedy  which  had  proved  most  efficacious  in  a  previous  case  present- 
ing similar  features,  so  far  as  we  possessed  the  means  of  discriminating. 
It  may  often  happen,  with  all  due  care,  that  a  diseased  surface  Avill 
remain  covered  and  protected  by  its  viscid  secretion,  so  that  an  appli- 
cation will  reach  the  more  healthy  portion  of  the  canal  alone.  We 
have  only  a  general  rule  to  guide  us  in  a  selection  of  remedies,  which 
is,  that  those  of  a  more  stimulating  character,  and  astringents,  are  more 
useful  for  diseases  confined  chiefly  to  the  neck  of  the  uterus,  while 
milder  alterations  are  best  adapted  for  the  upper  portion  of  the  canal. 

The  solid  nitrate  of  silver  acts  with  more  promptness  in  healing  an 
erosion,  and  in  arresting  a  profuse  secretion  from  the  cervical  canal 
than  any  other  agent,  Avith  th6  exception  of  those  Avhich  are  to  be 
classed  as  caustics  proper.  It  is  stimulating,  and  acts  as  a  powerful 
astringent  to  the  small  bloodvessels  Avithin  reach  of  its  influence,  so 
that  less  blood  passes  to  the  mucous  follicles,  and  their  secretion 
becomes  sufficiently  diminished  for  the  erosion  to  heal.  The  immedi- 
ate action,  however,  of  the  remedy  is  to  increase  the  secretion  of  these 
glands  by  a  Avatory  discharge,  until  the  vessels  have  contracted. 


APPLICATION    OF    CAUSTICS    TO    THE    OS.  133 

The  structure  of  the  cervix  is  naturally  more  dense  than  that  of  the 
body  of  the  uterus,  and  it  has  very  few  bloodvessels  in  comparison, 
but  it  is  covered,  as  is  the  vagina,  by  erectile  tissue  on  -which  its 
mucous  membrane  is  chiefly  dependent  for  its  vascularity.  So  long, 
therefore,  as  the  mucous  membrane  of  the  cervix  and  its  canal  can 
properly  perform  its  function,  so  long  will  the  tissues  remain  soft,  and 
the  induration  often  detected  in  the  neck  will  not  be  found  until  its 
mucous  follicles  or  glands  have  been  destroyed  or  their  number  greatly 
lessened. 

The  continued  use  of  the  nitrate  of  silver  is  as  certain  to  cause  con- 
traction of  the  OS,  and  to  bring  about  this  destruction  of  the  mucous 
glands  as  is  the  application  of  the  cautery,  and  it  has  been  productive 
of  more  harm  than  the  latter,  from  a  want  of  judgment  in  its  common 
use.  In  my  practice  I  cannot  count  more  than  half  a  dozen  cases 
treated  by  this  remedy  in  a  year.  It  is  applicable  only  when  the 
cervix  and  body  of  the  uterus  are  both  enlarged  and  soft,  and  the 
OS  patulous,  and  giving  issue  to  a  profuse  cervical  discharge.  I 
am,  then,  tempted  to  use  the  agent  only  when  the  patient  is  very 
anaemic,  and  it  is  absolutely  necessary  that  some  check  should  be 
placed  on  the  discharge  without  delay.  I  seldom  make  more  than  a 
single  application,  and  only  that  when  the  tissues  are  unusually  soft, 
as  above  described.  I  always  apply  it  with  great  care,  so  as  not  to 
include  the  tissues  immediately  about  the  os,  and  I  protect  this  surface 
by  a  suitable  instrument  if  the  caustic  is  passed  into  the  canal. 

For  the  cervix,  and  the  canal  below  the  internal  os,  I  frequently 
use  the  impure  carbolic  acid,  or  creasote-tar,  as  prepared  by  Dr.  Squibb 
for  commercial  purposes.  Its  action  is  entirely  different  from  that 
exerted  by  the  pure  carbolic  acid,  which  is  essentially  a  caustic  when 
used  undiluted.  It  is  an  alterative  as  well  as  an  astringent,  and  often 
exerts  a  marked  local  anaesthetic  effect.  Learning  from  Dr.  Squibb, 
some  seven  or  eight  years  ago,  that  he  had  observed  its  anaesthetic 
eifect  when  used  as  a  dressing  to  burns,  I  first  applied  it  to  the 
uterine  canal  and  to  the  female  bladder.  Since  that  time  I  have  used 
it  undiluted  ;  diluted  with  glycerine,  when  I  wished  a  milder  action  ; 
or  mixed  in  equal  parts  with  Churchill's  tincture  of  iodine,  to  increase 
its  alterative  effect.  It  coagulates  thoroughly  the  albuminous  dis- 
charges from  the  uterine  canal,  but  to  insure  full  efficiency,  it  is 
always  advisable  to  make  two  applications,  as  the  first  may  have  been 
partially  neutralized.  I  have  also  used  as  local  agents  pyroligneous 
acid,  and  pure  acetic  acid,  and  occasionally  creasote  alone,  or  in  com- 
bination Avith  iodine.    When  a  case  proves  more  obstinate,  equal  parts 


134  PRINCIPLES    OF    TREATMENT. 

of  chromic  acid  and  water  will  be  found  an  efficient  remedy,  one  not 
now  used  as  much  as  formerly,  since,  with  other  means  at  command 
for  more  general  treatment,  milder  local  agents  are  found  to  answer 
in  most  cases.    Water  is  the  proper  agent  with  which  to  dilute  chromic 
acid,  for  with  glycerine  it  forms  an  explosive  mixture.    As  adjuvants, 
tannin  and  the  pinus  Canadensis,  alone,  or  in  combination  with  glyce- 
rine, and   the    balsam  of   Peru  are   valuable  remedies.     A  serious 
objection  will  be  made  by  the  patients  to  the  use  of  either  of  the  last- 
named  agents,  as  their  linen  will  become  stained  by  them,  unless  the 
greatest  care  is  exercised.     This  accident  can  be  avoided  by  the  use 
of  a  napkin,  which  I  require  every  patient  to  Avear  during  the  day 
on  which  she  has  received  any  local  treatment.     The  pinus  Canaden- 
sis, as  furnished  to  the  profession,  when  first  introduced,  was  a  much 
more  efficient  remedy  than  the  article  now  found  in  the  market.     For 
some  reason  it  is  now  too  thin  and  watery,  and  I  have  been  obliged 
to  have  it  carefully  reduced  by  evaporation  in  a  sand  bath  to  the  con- 
sistency of  tar,  when  it  can  be  used  in  this  condition  or  diluted  with 
glycerine.     Glycerine  and  iodine  will  be  brought  more  into  use  than 
any  other  remedies,  and  are  applicable  in  some  form  for  all  varieties  of 
uterine  disease.    To  Dr.  Sims  we  are  indebted  for  the  use  of  glycerine 
in  the  treatment  of  these  diseases,  and  it  is  a  remedy  for  Avhich  we 
have  no  substitute.     As  a  solvent  or  vehicle  for  other  agents  it  is 
applicable  to  a  greater  extent  than  any  other  substance,  and  as  a  dis- 
infectant it  is  also  valuable.    When  placed  in  the  vagina,  it  provokes, 
in  consequence  of  its  avidity  for  moisture,  a  profuse  watery  discharge, 
which  empties  the  capillaries  without  apparently  taking  more  than  the 
serum,  or  robbing  the  blood  of  other  constituents,  to  the  detriment  of 
a  patient's  strength.     In  fact,  an  anaemic  patient  will  gain  strength 
from  its  constant  presence  in  the  vagina,  although  the  discharge  excited 
by  it  may  be  greater  than  the  previously  existing  leucorrhoea,  and  the 
fact  can  only  be  explained  on  the  supposition  that  the  glycerine  arrests 
the  escape  of  the  more  essential  constituents  of  the  blood.     The  loss 
of  albumen  in  the  leucorrhoeal  discharge  is  a  very  serious  one,  and 
when  constant,  it  becomes  an  important  factor  in  bringing  about  a 
condition  of  anaemia.     So  if  it'be  the  case  that  the  glycerine  removes 
only  the  watery  portions  of  the  blood,  and  by  some  action  arrests  the 
escape  of  the  albumen  and  the  other  component  parts,  its  value  as  a 
dressing  -will  be  readily  conceded.     It  has,  also,  the  same  power  as 
hot  water,  although  in  a  less  degree,  of  exciting  capillary  contraction, 
for  any  surface  which  has  been  long  in  contact  with  the  glycerine  will 
be  found  shrivelled  and  blanched  in  appearance. 


GLYCERINE — IODINE.  135 

After  the  examination  of  every  patient  I  have  heen  in  the  hahit  of 
leaving  in  the  vagina  a  portion  of  cotton  saturated  with  glycerine,  to 
which  a  string  is  attached,  that  the  patient  may  be  able  to  remove  it 
in  a  few  hours  when  it  begins  to  become  dry  and  irritating.  Cotton 
was  recommended  by  Dr.  Sims  as  the  vehicle  for  applying  glycerine 
in  this  manner,  and  has  been  in  use  for  fifteen  or  eighteen  years. 
Recently  I  have  employed  a  better  material  in  the  form  of  oakum, 
which  has  been  prepared  for  drainage  in  surgical  wounds.  I  have  for 
years  sought  a  substitute  for  the  cotton,  as  this  substance,  in  a  few 
hours,  Avill  become  matted  into  a  ball,  although,  on  its  introduction,  it 
may  have  been  spread  out  with  care  over  the  base  of  the  bladder.  If 
the  patient  should  neglect  to  remove  it,  after  it  has  gotten  into  this 
condition,  its  presence  will  often  cause  a  great  deal  of  irritation.  A 
small  portion  of  oakum  can  be  carefully  spread  out  and  compressed 
firmly  between  the  hands,  so  as  to  have  it  not  thicker  than  a  few 
sheets  of  paper,  nor  larger  than  some  two  and  a  half  inches  in  length, 
by  a  little  less  in  width.  For  its  removal,  a  short  cord  or  thread  can 
be  tied  across  the  middle,  but  not  tight  enough  to  prevent  the  pad 
from  lying  flat.  By  pouring  the  glycerine  over  the  oakum,  and  com- 
pressing this  with  the  fingers,  it  will  take  up  more  of  the  fluid  than 
the  same  bulk  of  cotton  is  able  to  do.  If  it  be  then  spread  out  on 
the  anterior  wall  of  the  vagina,  it  will  take  up  less  space  than  the 
cotton,  and  will  remain  perfectly  flat  until  it  is  removed.  When  dry, 
the  oakum  feels  harsh,  and  the  least  fitted  substance  for  the  pur- 
pose, but  if  saturated  Avith  glycerine  it  becomes  as  soft  as  the  finest 
moistened  sponge.  For  the  purpose  of  drainage,  this  material  is  un- 
equalled, while,  from  being  saturated  with  tar,  it  is  antiseptic,  and 
will  remain  in  the  vagina,  free  from  all  odor,  a  much  longer  time  than 
cotton. 

The  glycerine  should  always  be  of  the  best  quality  and  purchased 
from  a  reliable  dealer,  for  the  impure  article,  used  in  the  arts,  is  fre- 
quently substituted  on  account  of  its  lower  cost,  and  its  use  will  fre- 
quently cause  a  vaginitis  as  severe  as  that  produced  by  gonorrhoea. 

Iodine  has  proved  the  most  valuable  of  all  remedies,  and  it  is  one 
which  loses  nothing  of  its  efficacy  by  frequent  use.  It  is  not  only 
a  local  stimulant,  by  which  congestion  is  relieved,  but  is  likewise  a 
reliable  alterative  and  an  efficient  exciter  of  uterine  contraction.  It 
acts  promptly  in  causing  contraction  of  all  the  bloodvessels  within 
range  of  its  influence,  and  its  stimulating  effect  on  the  absorbents  is 
well  known.  Of  all  remedies  applied  within  the  uterine  canal,  iodine 
will  be  taken  up  into  the  general  circulation  the  soonest,  and  it  can  be 


136  PRINCIPLES    OF    TREATMENT. 

detected  by  the  taste  in  an  incredibly  short  space  of  time  ;  it  therefore 
acts  not  only  locally  but  also  as  a  general  alterative  on  nutrition.  It 
is  to  be  applied  not  merely  to  the  uterine  canal  but  frequently  to  the 
whole  vaginal  surface,  and  particularly  over  any  region  where  tender- 
ness can  be  detected  by  pressure  made  with  the  finger.  When  applied 
freely  to  a  surface  exposed  to  the  air,  iodine  will  frequently  blister, 
and  cause  great  pain,  therefore,  some  care  must  be  exercised,  that  it 
does  not  come  in  contact  Avith  the  outer  portion  of  the  vagina.  If,  by 
accident,  this  occurs,  the  surface  can  be  smeared  with  glycerine,  which 
will  promptly  relieve  the  burning  sensation  caused  by  it.  The  offici- 
nal tincture  of  iodine  was  long  in  use  for  the  treatment  of  uterine 
disease,  but  the  benefits  resulting  had  been  by  no  means  satisfactory 
or  reliable,  until  the  preparation  known  as  Churchill's  iodine  was 
employed.  To  the  late  Dr.  Churchill,  of  Dublin,  we  are  indebted  for 
this  preparation  Avhich  is  a  saturated  tincture,  and  about  four  times  as 
strong  as  the  ordinary  one. 

Unless  the  uterus  has  been  previously  dilated  it  will  be  necessary 
to  use  the  applicator  (see  page  30),  for  the  introduction  of  fluid 
substances  within  its  canal.  A  small  portion  of  long-fibre  cotton  is  to 
be  carefully  drawn  out  with  the  fingers  into  a  triangular  form,  as  thin 
as  possible,  and  about  three  inches  in  length.  From  one  corner  of 
the  triangle  the  cotton  should  be  twisted  tight  around  the  applicator, 
by  roling  it  in  the  firm  grasp  of  the  fingers.  It  is  then  necessary  to 
obtain,  by  means  of  the  uterine  probe,  the  exact  curve  and  direction 
of  the  canal,  and  this  can  best  be  done  by  placing  the  patient  on  the 
left  side,  Avith  the  cervix  brought  fully  into  view.  After  bending  the 
applicator  accurately  to  the  curve  indicated  by  the  probe,  the  cotton 
is  to  be  dipped  into  the  fluid  to  be  applied,  and  as  the  cervix  is  steadied 
by  a  tenaculum  held  in  the  other  hand,  the  instrument  can  be  passed 
to  the  fundus,  the  patient  being  in  the  same  position.  The  probe 
should  never  be  introduced  into  the  uterine  canal  with  less  care  than 
a  surgeon  would  exercise  in  exploring  the  tract  of  a  wound.  If  the 
importance  of  this  Avere  more  generally  appreciated,  cellulitis  would 
be  a  rare  occurrence  after  its  use.  If  a  digital  examination  be 
first  made  Avhile  the  patient  lies  on  the  back,  the  use  of  the  probe 
becomes  valuable  to  A'-erify  the  impression  conveyed  by  the  finger,  as 
to  the  position  of  the  uterus.  It  should  then  be  bent  to  correspond 
with  the  supposed  curve  of  the  canal,  or  direction  of  the  uterus,  and 
introduced  Avith  sufficient  care  to  enable  the  examiner  to  fully  appre- 
ciate any  deviation.  As  soon  as  this  is  detected  or  if  any  obstacle 
to  its  passage  is  felt,  the  instrument  should  not  be  forced,  but  Avith- 


APPLICATIONS    TO    THE    CANAL.  137 

drawn,  and  the  curve  altered  until  it  can  be  passed  to  the  fundus  with- 
out difficulty.  When  the  probe  is  manipulated  with  proper  care  and 
patience  we  will  rarely  find  any  obstruction  in  the  uterine  canal  which 
cannot  be  readily  overcome  after  the  true  direction  of  the  canal  has 
been  ascertained. 

It  is  by  no  means  an  unimportant  point  of  detail  that  the  applicator 
should  be  accurately  curved  to  correspond  with  the  uterine  canal.  It 
is,  indeed,  most  essential,  as  frec^uentl}'",  unless  this  precaution  be 
taken,  profuse  bleeding  Avill  occur  in  at  least  sufficient  quantity  to 
entirely  neutralize  the  effect  of  the  remedy  applied.  Even  did  no 
worse  result  follow  the  violent  introduction  of  tlie  applicator  than 
suffering  on  the  part  of  the  patient,  the  greatest  care  should  be  ex- 
ercised, and  it  will  be  found  after  some  experience  that  where  local 
applications  are  necessary  within  the  womb,  they  can  be  made  with- 
out producing  the  slightest  disturbance. 

If  it  be  desirable  (and  it  often  is),  the  cotton  may  be  left  in  the 
canal  with  a  portion  projecting  from  the  os,  as  it  will  cause  no  dis- 
turbance and  will  be  thrown  out  into  the  vagina  within  a  few  hours. 
To  facilitate  the  slipping  of  the  cotton  from  the  applicator,  it  is  only 
necessary,  after  twisting  it  on  tight,  to  hold  it  between  the  fingers  as 
the  flat  instrument  is  turned  in  the  opposite  direction.  This  leaves 
the  cotton  loose  on  the  applicator,  and,  when  passed  to  the  fundus, 
it  will  generally  remain  behind  as  the  instrument  is  withdrawn,  but 
if  not,  the  pressure  of  the  index  finger,  or  of  a  pair  of  forceps  against 
the  cotton  at  the  external  os  will  be  sufficient  to  disengage  it.  The 
advantage  of  this  is  twofold :  we  are  able  to  make  a  more  thorough 
and  lasting  application,  of  iodine  for  instance,  by  leaving  the  remedy 
longer  in  contact  with  the  diseased  surface,  and,  at  the  same  time  the 
uterus  is  stimulated  to  contraction  by  the  presence  of  a  foreign  body 
within  its  cavity.  This  is  a  convenient  method  also  for  the  intro- 
duction of  the  dry  persulphate  of  iron,  the  oxide  of  zinc,  alum,  or 
any  other  powdered  substance  employed  alternately  with  the  iodine. 
Before  the  cotton  has  been  loosened  on  the  applicator,  it  should  be 
dampened,  so  that  when  dipped  into  the  powder,  a  sufficient  quantity 
may  adhere  to  it.  When  powdered  substances  are  used  it  is  even 
more  important,  for  efficiency  in  the  application,  to  leave  the  cotton- 
within  the  canal,  than  it  is  when  fluids  are  employed. 

As  with  gleet  in  the  male,  so  here  the  pressure  or  presence  of  a 
foreign  body  in  the  canal  is  often  of  great  benefit,  not  only  by  lessen- 
ing the  discharge,  but  by  exciting  contraction  in  the  organ,  and 
giving  more  tone  to  the  vessels. 


138  PRINCIPLES    OF    TREATMENT. 

I  have  found  to  answer  Avell  for  this  purpose  tents  made  from  the 
pith  of  a  large  cornstalk,  as  recommended  by  Dr.  Goldsmith  of  Ga., 
for  dilating  the  canal.  The  doctor  kindly  sent  me  a  number  of  these 
tents  made  by  himself,  but  I  was  disappointed  in  their  limited  dilating 
power.  I  found  afterwards  that,  as  he  had  only  employed  the  strength 
of  his  fingers  to  compress  the  pith  into  tents,  the  full  force  of  the 
material  was  not  secured  by  this  mode  of  preparing  it.  After  the 
pith  had  been  soaked  for  several  hours  in  what  was  boiling  water 
at  the  beginning,  I  had  the  tents  prepared  after  the  same  method 
already  described  for  making  them  of  sponge,  with  the  exception  that 
no  mucilage  was  required,  in  consequence  of  the  different  character 
of  the  two  substances.  But  they  were,  in  the  same  manner,  com- 
pressed on  a  steel  staff  by  being  wrapped  as  tightly  as  possible  with 
a  cord,  then  removed,  bent  to  different  curves,  and  left  to  dry  before 
the  cord  was  taken  off.  While  these  tents  are,  by  comparison  with 
compressed  sponge,  of  inferior  value  for  dilating  the  uterine  canal, 
yet  they  answ^er  well  enough  when  only  a  moderate  degree  of  pressure 
is  required  for  producing  an  alterative  effect  on  the  mucous  membrane. 
The  surface  being  smooth  and  free  from  irregular  interstices,  the 
mucous  membrane  does  not  become  abraded  from  their  use  as  from 
sponge  tents  ;  they  entail,  therefore,  but  little  risk  of  blood  poisoning. 
As  the  pith  softens  slowly,  and,  for  a  time  is  as  unyielding  as  a 
sponge  tent,  it  is  always  prudent  for  the  patient  to  remain  quiet  for 
several  hours  after  its  introduction.  For  the  same  reason  it  is  more 
difiicult  than  with  a  sponge  tent  to  retain  the  pith  tent  in  the  canal, 
and  it  is,  therefore,  necessary  to  place  a  compress  of  oakum  or  cotton, 
saturated  with  glycerine,  against  the  cervix.  I  have  found  that  dip- 
ping a  tent  of  this  material  into  iodine,  and  then  introducing  it  within 
the  canal,  is  a  very  thorough  method  of  applying  that  agent. 

In  hospital  practice,  when  I  could  control  the  movements  of  the 
patient,  I  have  long  employed  sponge  tents  to  bring  about  a  reduction 
in  the  size  of  an  enlarged  uterus.  This  mode  of  practice  was  original 
with  me,^  and  from  long  experience  I  have  found  it  most  satisfactory 
when  employed  under  proper  circumstances.  The  object  is  to  bring 
about  by  pressure  an  alterative  effect  in  the  mucous  membrane  and 
indurated  tissue,  to  excite  contraction  of  the  Avhole  organ,  and  to 
lessen  the  circulation  iii  the  uterus  through  the  profuse  water}^  dis- 
charge induced  by  the  presence  of  this  foreign  body  in  the  canal. 

I  cause  the  bowels  to  be  moved  with  medicine,  or  by  an  enema,  on 

1  See  Uterine  Surgery,  by  Dr.  J.  M.  Sims,  p.  G5. 


DILATING    THE    OS.  139 

the  morning  of  a  clear,  bright  clay,  and,  if  the  strength  of  the  patient 
will  admit  of  it,  I  direct  that  she  shall  remain  in  the  open  air  for 
several  hours  before  being  seen  by  me,  as  she  must  be  confined  to  the 
house  afterwards  for  at  least  two  days.  A  bright,  clear  day,  with 
the  wind  from  any  ((uarter  except  from  the  east,  I  always  select  for 
dilating  the  uterus,  or  for  performing  any  serious  surgical  operation. 
My  reasons  for  doing  so  are,  in  the  first  place,  that  under  such  cir- 
cumstances I  am  myself  in  better  condition,  but  chiefly  that  the 
nervous  system  of  a  patient  will  be  less  taxed,  and  the  power  of  endu- 
rance greater  on  a  clear  day.  Moreover,  experience  has  taught  me 
that  in  a  state  of  the  atmosphere  favorable  to  an  active  condition  of 
the  skin,  there  will  always  be  less  danger  from  blood  poisoning.  I 
have  also  been  impressed  with  the  conviction  that  the  occurrence  of 
cellulitis  is  a  far  more  frequent  sequel  to  the  use  of  the  sponge  tent, 
when  emplo3^ed  during  the  prevalence  of  damp,  cold,  and  easterly 
weather,  even  when  the  patient  is  confined  to  the  house  and  protected 
from  all  exposure. 

As  I  strictly  observe  the  predilection  in  favor  of  clear  weather 
and  the  rules  I  have  already  detailed  when  considering  the  use  of 
sponge  tents,  my  practice  for  years  has  been  almost  entirely  free 
from  any  bad  consequences  attending  their  use.  I  introduce  as  large 
a  tent  as  possible,  without  using  violence,  and,  if  the  canal  is  not 
straight,  I  carefully  select  a  tent  of  the  proper  curve.  The  patient 
is  then  placed  in  bed,  as  I  have  described,  and  a  hot  water  vaginal 
injection  is  given,  night  and  morning,  and  an  opiate,  if  needed.  At 
first,  even  should  there  have  been  no  pain,  I  remove  the  tent  at  the 
end  of  twenty-four  hours,  but,  after  several  have  been  employed,  I 
allow  it  to  remain  for  thirty-six  or  forty-eight  hours,  that  the  patient 
may  obtain  the  benefit  of  the  profuse  Avatery  discharge  which  takes 
place.  When  I  finally  remove  the  tent,  I  jjlace  the  patient  on  her 
ba'ck  over  a  bed-pan,  and  alongside  of  my  finger  I  pass  the  nozzle  of 
a  Davidson's  syringe  to  the  fundus,  and  inject  a  stream  of  hot  water 
into  the  cavity,  until  the  organ  has  contracted  on  my  finger.  I  then 
place  the  patient  on  the  side,  introduce  the  speculum,  seize  the  cervix 
with  a  tenaculum,  and  pack  some  cotton  about  it,  to  receive  the  excess 
of  iodine,  which  is  to  be  introduced  into  the  canal.  The  iodine  may 
be  either  injected  by  pressing  the  nozzle  of  the  syringe  to  the  fundus, 
or  applied  by  means  of  the  applicator,  leaving  the  saturated  cotton 
within  the  canal ;  but  it  will  be  necessary  to  use  a  larger  mass  of 
cotton  than  would  be  employed  were  the  canal  not  dilated. 


140  PRINCIPLES    OF    TREATMENT. 

In  all  cases  it  is  essential  that  the  patient  remain  in  iDed  for  twenty- 
four  hours  after  dilating  the  uterus,  and  applying  the  iodine  by  this 
method.  If  the  application  should  be  followed  by  an  increase  of 
backache,  or  any  other  disturbance,  the  patient  should  remain  in  bed 
for  a  longer  period  of  time,  and  prudence  would  dictate  the  necessity 
of  avoiding  all  over-exertion  during  a  few  days  longer. 

On  account  of  the  confinement,  and  in  order  that  the  patient's 
health  may  not  suffer  from  it,  it  is  seldom  advisable  to  repeat  this 
mode  of  treatment  oftener  than  twice  during  a  month,  and  then  to  so 
regulate  it  that  at  least  an  interval  of  ten  days  should  elapse  between 
the  last  dilatation  and  the  appearance  of  the  catamenia. 

Early  in  1863  I  injected  Churchill's  iodine  into  the  dilated  uterine 
canal,  with  the  view  ef  exciting  still  more  the  uterine  contraction  after 
the  use  of  sponge  tents.  I  had  observed  this  effect  during  the  pre- 
vious year  that  I  had  been  using  the  remedy,  prepared  according  to 
the  formula  now  in  general  use,  but  which  was  then  procured  by  Dr. 
Sims  for  me  from  Dr.  Churchill.  Towards  the  close  of  the  year,  or 
early  in  1861,  I  injected,  at  the  Woman's  Hospital,  the  dilated  uterus 
of  a  young  woman  who  had  suffered  from  malarial  congestive  hyper- 
trophy, when  the  organ  contracted  so  suddenly,  and  with  such  force, 
as  to  expel  a  portion  of  the  iodine  from  the  uterine  cavity,  entirely 
out  of  the  vagina,  as  from  a  squirt.  In  this  case  I  was  assisted  by 
Dr.  John  G.  Perry,  then  house  surgeon.  His  predecessor.  Dr.  Gr. 
S.  Winston,  had  also  observed  with  me  this  effect  in  the  treatment  of 
other  cases,  but  in  a  less  marked  degree.^  No  one,  previous  to  my- 
self, had  followed  this  plan  of  treating  hypertrophy  of  the  uterus,  nor 
had  any  one  recognized  iodine  as  an  agent  for  exciting  prompt  uterine 
contraction. 

The  passage  of  a  continuous  stream  of  hot  water  into  the  uterine 
cavity,  after  thorough  dilatation  of  the  canal  with  the  view  of  causing 
rapid  contraction,  and,  at  the  same  time,  bringing  about  a  modified 
action  in  the  mucous  membrane  itself,  is  a  practice  I  believe  to  be  also 
original  with  me. 

If  the  condition  of  the  patieyt  be  one  justifying  the  use  of  sponge 
tents,  and  if  she  be  properly  situated  for  receiving  this  treatment, 
the  effect  of  hot  water  will  prove  most  satisfactory  in  its  results. 

1  Until  the  publication  of  Dr.  Sims's  work  on  Uterine  Surgery,  in  1-666,  I  was  not 
aware  that  any  one  hut  myself,  unless  through  my  advice,  had  ever  injected  the 
uterus  with  iodine  to  arrest  hemorrhage.     Dr.  Sims  describes,  in  his  work,  this  ■ 
plan  as  tlien  being  the  mode  of  treatment  emijloyed  by  Dr.  Savage  in  the  Samari- 
tan Hospital,  London. 


INJECTIONS    INTO    THE    UNDILATED    UTERUS.  141 

The  direct  action  of  hot  water  on  the  interior  of  the  uterine  canal  is 
even  more  beneficial  than  is  its  indirect  action  from  the  vao;ina.  In 
connection  with  the  modifying  effect  of  pressure  from  the  tent,  and  the 
free  application  of  iodine  afterwards,  I  have  found  hot  water  to  exer- 
cise a  more  decided  action  in  checking  excessive  secretion  from  the 
mucous  glands,  than  can  be  gained  by  the  introduction  of  any  remedy 
into  the  undilated  canal,  unless  the  agent  be  such  as  will  destroy  the 
character  of  the  mucous  membrane,  when,  of  course,  all  secretion  will 
cease.  The  good  effects  of  this  mode  of  treatment  are  not  confined 
to  cases  of  enlargement  of  the  uterus.  It  is  equally  beneficial,  if 
not  more  so,  Avhere  there  exists  no  enlargement,  since  the  disease  is 
then  confined  chiefly  to  the  cervix,  or  at  least  to  that  portion  of  the 
canal  below  the  internal  os.  By  dilating  the  canal  thoroughly,  in 
these  cases,  we  will  open  out  the  rugae,  so  that  the  agent  applied  can 
be  brought  directly  in  contact  with  the  mouth  of  each  crypt  and  every 
portion  of  the  mucous  membrane.  This  cannot  be  done  under  ordi- 
nary circumstances,  and  the  fact  will  explain  the  negative  result,  fre- 
quently observed  after  applications  made  through  an  undilated  os, 
for  the  nearer  the  uterus  approaches  to  a  natural  size,  the  deeper  will 
these  folds  be  found. 

The  undilated  uterus  should  never  be  injected,  since  the  mildest 
and  most  unirritating  substance  throAvn  into  the  uterine  canal,  when 
in  this  condition,  will  often  cause  a  profound  degree  of  collapse,  fre- 
quently cellulitis,  and  almost  always  pain.  It  has  been  supposed 
that  the  difficulty  arose  from  fluid  passing  through  the  Fallopian  tubes, 
and  so  coming  in  contact  with  the  peritoneum. 

But  this  explanation  is  based  entirely  upon  theoretical  grounds, 
for  we  know  in  practice  that  the  peritoneum  is  not  so  immediately 
responsive  to  contact  Avith  other  substances,  although  it  is  true  an 
attack  of  peritonitis  would  be  likely  to  follow  such  an  accident.  It  is 
not  necessary  that  any  portion  of  the  fluid  should  escape  from  the  ute- 
rine cavity  in  order  to  produce  the  most  serious  consequences.  This 
is  proven  by  a  death  which  occurred  a  short  time  since  in  one  of  the 
Western  cities,  where  a  woman,  in  good  general  health,  died  instantly 
with  nothing  more  than  a  slight  convulsive  movement,  after  a  small 
quantity  of  Churchill's  iodine  had  been  injected  into  the  undilated 
uterine  canal.  In  this  case,  as  I  have  been  informed,  the  post-mortem 
examination  revealed  the  important  fact  that  no  portion  of  the  iodine 
had  passed  into  the  Fallopian  tubes,  nor  into  the  uterine  sinuses.  We 
will  have  to  seek  an  explanation  in  some  effect  on  the  nerve  centres, 
by  which  a  reaction  from  sudden  shock  is  prevented.     In  our  igno- 


142  PRIXCIPLES    OF    TREATMEXT. 

ranee,  "^e  must  rest  satisfied  with  the  practical  fact  Tvliicli  has  been 
fully  established,  that  when  the  canal  is  sufficiently  dilated  for  the 
free  escape  of  fluids,  it  may  be  injected,  not  only  with  impunity, 
but  even  with  benefit.  Of  all  the  various  devices  which  have  been 
conceived  for  injecting  the  uterine  canal,  not  one  can  be  used  with 
absolute  safety. 

'Slj  old  friend,  the  late  Dr.  J.  C.  Nott,  was  very  expert  in  injecting 
the  uterus,  and  devised  the  best  canula  in  use  for  the  purpose.  Some 
years  ago,  when  the  Woman's  Hospital  was  under  my  charge,  Dr. 
Nott  was  on  duty  as  an  assistant  surgeon,  and  was  very  anxious  to 
demonstrate  the  advantages  of  this  mode  of  treatment.  His  senice 
consisted  of  twenty  beds,  and  in  one  Aveek  after  going  on  duty,  about 
fifteen  of  his  patients  were  down  with  cellulitis  ;  fortunately  none  of 
them  died,  but  several  were  very  ill,  and  remained  in  the  hospital 
afterwards  for  tAvo  years  or  more  before  they  were  relieved  of  the 
consequences.  The  doctor  had  been  particularly  fortunate  in  private 
practice,  but  this  experience  led  him  to  abandon  the  mode  of  treatment. 
-  Blistering  the  cervix  occasionally  Avill  be  found  a  useful  adjuvant 
to  other  treatment.  It  is  of  value  Avhen  the  Avhole  uterus  is  enlarged, 
and  particularly  when  the  cervix  has  been  indurated.  The  bHster 
causes  a  very  free  watery  discharge  which  relieves  the  congestion, 
and  at  the  same  time  stimulates  the  organ  to  contraction.  When  the 
cervix  has  become  indurated,  the  blister  is  beneficial  for  its  revulsive 
efiect,  but  it  will  be  of  little  service  should  the  mucous  membrane  of 
the  cervix  have  been  destroyed  by  the  long-continued  use  of  nitrate  of 
silver  or  other  caustics.  Under  these  circumstances,  Ave  will  be  obliged 
to  employ  a  surgical  procedure,  to  be  described  hereafter. 

Some  ten  years  ago,  I  was  in  the  habit  of  using  A^esicating  collodion, 
but  abandoned  it  in  consequence  of  being  unable  to  confine  the  action 
of  the  blister  to  the  cervix.  As  the  cantharides  Avas  held  in  solution 
by  so  volatile  a  substance  as  the  ether,  the  Avhole  A-agina  Avould  often 
become  blistered.  Shortly  afterwards,  I  found  on  the  market  a  solu- 
tion of  cantharides  in  acetic  acid,  which  has  ansAvered  fully  every 
purpose,  since  its  action  can  be  confined  to  the  most  limited  space, 
when  so  desired. 

I  have  the  patient  previously  prepared  by  a  moA^ement  of  the 
boAvels,  that  there  may  be  no  necessity  to  get  up  for  a  day  or  tAvo. 
In  applying  the  blister,  the  patient  is  placed  on  the  left  ,side,  and  the 
cerAdx  brought  into  vieAV  by  the  aid  of  Sims's  speculum.  I  am  in  the 
habit  of  draAving  the  cervix  a  little  forward  Avith  a  tenaculum,  and 
then,  with  a  pair  of  forceps,  packing  a  small  portion  of  cotton  around 


BLISTERS    TO    THE    OS.  143 

the  cervix,  hut  chiefly  below,  that  the  fluid  may  be  prevented  from 
ruuniui^  on  to  the  vaginal  surface.  The  blistering  fluid  may  then  he 
applied  with  a  camcl's-hair  pencil,  or  by  means  of  a  little  cotton 
twisted  around  tiie  end  of  the  swab-stick.  AVhen  a  thorough  action 
is  required,  the  blistering  fluid  can  be  rubbed  over  the  same  surface 
until  it  has  become  of  a  gray  color.  It  must  be  allowed  a  moment  or 
two  to  dry,  when  the  surface  will  be  found  to  have  become  shrivelled, 
and,  for  a  time,  the  whole  neck  will  remain  reduced  in  size.  The 
patient  is  to  be  kept  quiet  in  bed,  the  vaginal  injections  being  omitted 
for  three  or  four  days,  until  the  discharge  becomes  copious.  It  is 
seldom  that  there  will  be  any  backache  or  discharge  under  twenty- 
four  hours,  and,  if  the  patient  keeps  the  horizontal  position,  the  former 
can  be  avoided.  After  the  fifth  day  the  parts  will  heal  rapidly  under 
the  use  of  injections,  night  and  morning,  of  warm  (not  hot)  Avater  to 
which  a  little  Castile  soap  has  been  added.  After  the  morning  injec- 
tion a  pledget  of  oakum,  saturated  with  glycerine,  should  be  laid  over 
the  raw  surface  daily,  and  removed  by  a  string  attached  to  it,  Avhen- 
ever  it  begins  to  be  uncomfortable.  When  the  whole  cervix  has  been 
blistered,  it  is  necessary  that  the  patient  should  remain  in  bed  from 
four  to  six  days,  and,  until  the  discharge  ceases,  she  should  not 
expose  herself  to  the  risk  of  taking  cold  nor  to  the  dangers  of  over- 
exertion. 

After  this  agent  has  been  applied,  in  the  manner  described,  the 
epithelium  alone  is  removed  from  the  mucous  membrane,  and  the 
whole  surface  is  generally  healed  in  seven  or  eight  days,  although  it 
may  remain,  for  a  few  days  longer,  of  a  deeper  color  than  natural. 
When  applying  the  fluid,  to  prevent  its  entrance  into  the  canal,  a 
little  cotton  may  be  inserted  within  the  os,  and,  as  a  precaution,  it  is 
especially  necessary  to  do  so  when  the  os  is  much  smaller  than  natural. 
I  have  carefully  watched  the  after-ertects  of  this  remedy,  and  I  have 
never  seen  any  evidence  of  narroAving  of  the  os  produced  by  its  use. 
But  it  will  sometimes  cause  great  pain,  and  much  backache  afterwards, 
if  the  fluid  be  allowed  to  run  into  a  canal  Avith  a  constricted  os.  When 
the  discharge  is  free,  and  the  os  Avell  open,  I  have  sometimes  inten- 
tionally applied  the  fluid  to  the  lining  membrane  of  the  canal  to  bring 
about  an  alterative  eflect  in  the  mucous  glands,  sometimes,  as  I  have 
thought,  Avith  a  result  decidedly  beneficial,  but  its  use,  in  this  manner, 
Avas  always  attended  Avith  more  pain  than  when  applied  to  the  cervix 
alone. 

There  are  certain  practical  points  Avhich  should  never  be  lost 
sight  of  in  connection  Avith  the  local  treatment,  to  which  I  shall  again 


144  PRINCIPLES    OF    TREATMENT. 

call  the  attention  of  the  reader.  We  should  have  the  fear  of  cellulitis 
always  before  us,  in  the  treatment  of  these  diseases,  and  as  common 
as  this  complication  is  from  cold  and  other  causes,  it  has  its  origin 
quite  as  frequently  in  carelessness  on  the  part  of  the  practitioner. 

We  should  never  introduce  the  probe,  a  sponge  tent,  or  make 
an  application  within  the  uterine  cavity,  if  the  slightest  indication 
of  cellulitis  can  be  detected.  Nor  should  Ave  attempt  to  correct  a 
displacement  of  the  uterus,  if  cellulitis  exists,  or  as  long  as  any 
tenderness,  attributable  to  inflammatory  origin,  can  be  detected  on 
pressure  by  means  of  the  finger.  But  we  must  discriminate  between 
a  condition  of  hypersesthesia,  to  be  found  in  anaemic  and  hysterical 
women,  and  one  of  inflammation,  since  an  error  of  diagnosis,  although, 
on  the  one  hand,  resulting  merely  in  a  loss  of  time,  may,  on  the  other, 
result  in  a  loss  of  the  patient.  It  is,  therefore,  better  in  all  cases  of 
doubt  to  give  the  patient  the  benefit  of  some  preparatory  treatment. 

After  an  application  to  the  uterine  cavity,  rest,  for  a  time,  in  the 
horizontal  position  is  always  advisable,  and  this  precaution  is  particu- 
larly to  be  observed  when  an  application  is  made  for  the  first  time. 
It  is  equally  prudent  to  observe  the  same  precaution  after  replacing 
the  uterus  for  the  first  time  ;  and,  when  there  has  been  much  pain 
produced,  or  difficulty  experienced  in  the  reduction,  I  generally  insist 
upon  the  patient  remaining  in  bed  until  all  danger  has  passed.  In  my 
private  hospital  the  rule  is  for  every  patient  to  lie  down  after  any 
application  to  the  uterine  canal,  to  have  some  covering  thrown  over 
them,  and  heat  applied  to  the  feet  if  they  should  be  cold.  In  my 
of&ce  practice,  I  often  retain  outside  patients  for  hours  as  a  matter 
of  prudence,  and,  when  advisable  to  do  so,  I  keep  them  until  next  day 
or  longer.  When  an  operation  has  been  performed  or  an  application 
has  been  made  to  the  uterus,  of  sufficient  severity  to  make  it  prudent 
that  the  patient  should  remain  in  bed,  she  is  not  allowed  to  assume 
the  upright  position,  but  is  lifted  into  bed  after  the  sheets  have  been 
warmed,  and  a  vessel  of  hot  water  placed  for  her  feet.  As  long 
as  we  are  able  to  keep  the  feet  warm,  danger  from  cellulitis  will  be 
slight.  A  patient  is  never  to  be  allowed  to  put  her  feet  out  of  bed  as 
long  as  it  is  necessary  that  she  should  remain  there.  If  she  should 
be  unable  to  empty  the  bladder  on  a  bed  pan,  the  catheter  must  be 
resorted  to.  •  To  this  imprudent  act  of  getting  out  of  bed,  so  commonly 
committed  by  women,  without  thought  of  the  consequence,  may  be 
traced  many  an  attack  of  cellulitis,  brought  on  by  the  sudden,  although 
momentary  (it  may  be),  exposure  of  the  feet  to  cold.  It  has  caused 
more  disease    in    women    who   were  previously  healthy,  than  could 


IMPORTANCE  OF  DETAILS.  145 

result  from  any  other  single  act  of  imprudence,  within  their  power 
to  commit,  and,  to  mj  knowledge,  several  deaths  have  occurred 
from  pelvic  abscesses  where  patients  have  disregarded  the  precautions 
enjoined,  when  under  treatment  for  previous  diseases. 

However  trivial  or  unnecessary  these  details  may  seem  to  be,  their 
importance  is  not  exaggerated,  for  experience  has  taught  me  that  in  the 
observance  of  every  precaution  lies  the  secret  of  immunity  and 
success. 

Before  closing  this  portion  of  our  subject,  let  us  recapitulate  briefly 
the  principles  which  are  to  govern  us  in  the  use  of  local  means  for  the 
treatment  of  these  diseases.  Our  chief  purpose  is  to  be  directed  to 
giving  tone  to  the  pelvic  vessels,  and  to  placing  the  uterus  in  a  position 
where  the  circulation  will  be  the  least  obstructed.  The  first  is  to  be 
accomplished  by  the  frequent  use  of  hot  water  injections,  given  in  a 
favorable  position,  by  Avhich  the  vessels  will  be  more  contracted  after 
they  have  been  somewhat  emptied  of  their  contents  by  the  action  of 
gravity.  The  second  is  to  be  gained  by  a  properly  constructed 
pessary  to  suit  the  individual  peculiarities  of  the  case.  Pessaries, 
however,  should  never  be  employed  while  cellulitis  exists,  or  when 
the  position  or  condition  of  the  uterus  indicates  the  necessity  for 
preparatory  treatment,  there  being  a  proper  time  and  mode  of  apply- 
ing pessaries  to  advantage,  the  same  as  there  is  for  splints  in  the 
treatment  of  a  fracture.  All  our  other  local  remedies  are  to  be 
employed  as  aids  in  carrying  out  the  same  principles,  by  which  in- 
crease in  size  is  to  be  reduced,  and  augmented  secretion  diminished 
by  improvement  in  nutrition,  and  a  restoration  of  the  equilibrium  of 
the  circulation.  Withal,  we  must  carefully  discriminate  between 
cause  and  effect,  and  bear  in  mind  that,  as  a  rule,  the  local  condition 
is  but  an  expression  of  the  state  of  the  whole  body.  Therefore,  the 
local  condition  is  not  likely  to  be  permanently  benefited,  unless  we 
can  at  the  same  time  improve  general  nutrition,  by  a  careful  and  well 
regulated  constitutional  treatment. 

The  female  organs  of  generation  have  been  mercifully  endowed 
with  a  degree  of  tolerance  to  injury  not  possessed  by  the  male,  and 
woman  is  thus  protected  that  she  may  be  able  to  bear  the  perils  of 
gestation.  But  few,  however,  of  the  many  physicians  who  undertake 
to  treat  these  diseases  fully  realize  that  there  is  naturally  a  limit  to 
this  immunity.  No  portion  of  the  body  has  suffered  more  in  consequence 
of  incapacity  on  the  part  of  members  of  the  profession,  many  of  whom, 
from  ignorance,  have  been  unable  to  appreciate  in  detail  the  true 
bearing  of  all  pertinent  points.  Nor  have  women  suff"ered  much  less 
10 


146  PRINCIPLES    OF    TREATMENT. 

from  the  gross  carelessness  of  some,  in  not  making  a  thorough  in- 
vestigation, even  when  thej  may  have  possessed  the  requisite  know- 
ledge. Under  the  guise  of  surgery,  the  uterus  has  been  subjected  to 
a  degree  of  mal-practice,  which  would  not  have  been  tolerated  in  any 
other  portion  of  the  body.  Its  cavity  has  been,  and  is  still  made  the 
receptacle  for  agents  so  destructive,  that  no  conscientious  man  would 
employ  them  for  the  treatment  of  disease  in  any  other  cavity  of  the 
body  without  a  full  appreciation  of  his  responsibility.  But  I  trust 
that  we  have  already  passed  the  heroic  age,  and  that  in  the  treatment 
of  these  diseases,  we  may  be  governed  hereafter  by  the  same  rational 
principles  as  would  be  applicable  elsewhere,  that  we  may  simply,  as 
we  term  it  in  this  country,  exercise  our  "  common  sense." 


PUBERTY.  147 


CHAPTER    IX. 

OVULATION  AND  MENSTRUATION. 

Nerve  supply  of  the  ovaries — Puberty — The  uterus  not  the  dominant  organ  of  the 
female — Menstruation  not  always  due  to  ovulation — Disintegration  of  the  lining 
membrane  of  the  iiterus  during  menstruation — Causes  which  determine  early 
or  late  menstruation — Table  I.,  showing  age  at  first  menstruation,  for  single, 
sterile,  and  fruitful  women  ;  and  whether  menstruation  was  regular  or  not — 
Table  II.,  showing  the  percentage  on  the  whole  number  menstruating  at  a  given 
age — Table  III.,  showing  the  percentage  in  relation  to  regularity  or  irregularity 
— Table  IV.,  regularity  further  analyzed — Table  V.,  pain  during  menstruation 
in  reference  to  health,  disease,  and  sterility — Table  VI.,  showing  proportion 
suffering  pain  with  menstruation  for  each  menstrual  age — Table  VII.,  showing 
further  relation  of  pain  to  menstruation — TaVjle  VIII.,  pain  during  menstruation 
for  all  conditions — Table  IX.,  showing  average  duration  of  the  flow — Table  X., 
showing  duration  of  flow  with  reference  to  circumstances  of  first  menstruation — 
Table  XL,  changes  in  duration  of  flow  in  after-life — Table  XII.,  menstrual 
changes  as  to  quantity  and  duration. 

The  ovaries  are  supplied  with  nerves  from  the  solar  plexus,  forming 
a  part  of  the  great  ganglionic,  or  sympathetic  system,  and  the  nutri- 
tive functions  are  under  the  same  influence. 

At  a  certain  age,  a  stimulus  is  given  to  the  nutritive  functions 
through  the  influence  excited  by  the  ovaries,  which  results  in  a  rapid 
physical  growth  of  the  female.  When  the  ovaries  have  reached  their 
full  development,  the  transition  from  girlhood  to  womanhood  takes 
place  at  the  period  termed  puberty.  The  expression  of  this  climax  is 
noted,  in  a  properly  organized  condition,  by  a  discharge  of  blood  from 
the  uterine  canal.  This  discharge  of  blood  is  called  the  menstrual 
flow,  which  returns  at  regular  intervals,  until  a  certain  period  of 
middle  life,  Avhen  the  ovaries  become  atrophied  and  cease  to  exercise 
any  further  influence. 

During  the  menstrual  life,  the  ovarian  influence  is,  in  health,  the 
dominant  power.  Through  the  aid  of  the  sympathetic  system,  it  ex- 
ercises as  important  a  part  in  the  organization  as  the  fly-wheel,  or 
governor,  in  regulating  the  power  and  speed  of  a  well-constructed 
engine. 

The  ovaries  are  the  egg-bearing  organs  of  the  female.     The  eggs, 


148  OVULATION    AND    MENSTRUATION. 

germs,  or  ova,  exist  in  large  numbers  in  each  ovary,  being  contained 
in  ovisacs  called  the  Graafian  follicles.  As  maturation  progresses, 
the  ovisac,  or  follicle,  becomes  more  vascular,  and  enlarges  by  the  ac- 
cumulation of  a  serous  fluid  within  its  cavity.  In  this  way  it  ap- 
proaches and  finally  projects  upon  the  surface  of  the  ovary.  At  the 
proper  time,  it  ruptures,  when  the  ovum  escapes  and  is  seized  by  the 
fimbriated  extremity  of  the  oviduct,  or  Fallopian  tube,  and  carried 
along  this  canal  into  the  uterine  cavity,  where  it  becomes  impregnated 
under  favoring  circumstances. 

It  was  formerly  believed  that  the  uterus  exercised  at  all  times, 
during  menstrual  life,  the  greater  influence  in  the  female  economy, 
but  further  investigation  has  shown  that  this  and  the  other  organs  of 
generation  are,  under  ordinary  circumstances,  but  appendages,  as  it 
were,  to  the  ovaries.  During  pregnancy,  however,  the  force  of  the 
uterus  becomes  paramount,  and  that  of  the  ovaries  rests,  for  the  time, 
quiescent.  It  is  a  fact  well  known  that  the  ovaries  are  not  unfre- 
quently  found  fully  developed  when  the  uterus  and  vagina  are  wanting, 
but  that  the  uterus  never  reaches  its  full  size  if  the  growth  of  the  ova- 
ries is  deficient.  Again,  if  from  any  cause,  in  after  life,  atrophy  of 
both  ovaries  should  take  place,  by  which  their  function  become  im- 
paired, the  uterus  also  decreases  in  size,  and  its  office  ceases. 

The  view  is  still  held  by  m.any  that  the  menstrual  flow  is  always 
due  to  ovulation,  but  recent  observations  indicate  that  this  is  not 
correct.  The  subject  is  still  one  of  great  obscurity,  from  the  difficulty 
of  observation  in  the  human  female,  and  if  ever  settled  it  will  proba- 
bly be  by  the  study  of  the  function  as  performed  in  other  animals  that 
are  nearest  allied  to  the  human  species. 

One  point  is  settled  beyond  question,  that  the  first  menstrual  flow  is 
dependent  on  the  final  and  complete  development  of  the  ovary.  In  other 
words,  menstrual  life  never  begins  until  the  ovaries  have  been  devel- 
oped, so  far  as  the  vital  forces  of  the  individual  will  admit,  to  a  full 
physiological  standard. 

There  exists,  frequently,  a  coincidence  between  ovulation  and  the 
occurrence  of  the  menstrual  flow.  But  it  is  claimed  that  this  flow 
frequently  takes  place  Avithout  the  rupture  of  a  Graafian  vesicle, 
while  ova  are  developed  in  the  earliest  infancy,  during  lactation,  and 
even  in  after  life,  when  the  menstrual  flow  has  ceased.  Instances  are 
not  rare  where  conception  has  taken  place  before  the  menstrual  flow 
has  ever  appeared,  and  consecutive  pregnancies  are  known  to  have 
occurred  in  the  absence  of  the  catamenia.  I  have,  myself,  met  with 
one  instance  in  which  the  woman  had  borne  two  children  before  her 


CONCEPTION.  149 

first  menstrual  period,  at  eighteen  years  of  age.  I  have  had  also, 
under  my  care,  three  cases  in  which  conception  occurred  during  the 
prolonged  absence  of  the  menstrual  flow,  after  a  previous  pregnancy  ; 
of  these,  one  miscarried,  and  two  went  to  full  term.  It  has  even 
been  noted  that  ovulation  occurs  sometimes  during  the  existence  of 
pregnancy. 

We  are  ignorant  of  the  length  of  time  necessary  for  the  ovum  to 
reach  the  uterus  after  it  has  once  entered  the  Fallopian  tube.  But 
the  ovum  either  possesses  a  remarkable  degree  of  vitality,  or  it  does 
not  reach  the  cavity  of  the  uterus  before  the  flow  takes  place.  For 
it  is  a  fact  well  attested  that  conception  may  occur  at  any  time  during 
the  interval  between  the  flow,  although,  as  a  rule,  it  takes  place 
shortly  after  menstruation  has  ceased.  The  inference  is  a  fair  one, 
that  impregnation  is  frequently  effected  before  menstruation  begins, 
or  that  the  ovum  does  not  enter  the  uterine  ca-\aty  until  the  flow  has 
ceased.  "VVe  cannot  otherAvise  explain  the  fruitfulness  so  common 
among  the  Hebrews.  I  have  been  informed  by  some  of  my  patients 
of  this  faith  that  a  woman  is  considered  unclean  for  five  days  before 
the  period,  and  for  a  week  after  the  flow  has  ceased,  and  that  the  law 
is  religiously  observed  in  having  no  intercourse  with  their  husbands 
during  this  interval.  I  am  without  the  necessary  data  to  prove  the 
assertion,  but  am  under  the  impression  that  the  average  duration  of 
the  menstrual  flow  is  rather  longer  for  women  of  this  race  than  for 
those  of  our  own  people.  I  had  been  informed  of  the  general  ob- 
servance of  the  law,  and  a  knowledge  of  it  led  me  to  make  some  in- 
quiry in  a  case  which  I  now  recall.  This  was  a  lady  whose  flow  had 
always  lasted  a  week ;  she  was  the  mother  of  a  large  number  of 
children.  She  came  under  my  care  for  excessive  menstruation,  which 
was  then  prolonged  to  ten  days.  She  assured  me  that  she  scrupu- 
lously observed  the  law  of  her  people,  and  yet  she  became  pregnant 
twice,  to  my  knowedge,  during  the  six  days  only  which  remained  in 
the  month.  She  became  pregnant,  therefore,  between  the  seventeenth 
and  twenty-third  days,  after  the  beginning  of  one  period,  or  between 
the  eleventh  and  twenty-fifth  day,  before  the  next  one  began. 

The  connection  between  occurrence  of  ovulation  and  the  menstrual 
flow  has  recently  been  investigated  by  Slaviansky  and  others.  As 
the  result  of  their  observations,  it  is  shown  that  the  two  processes  are 
distinct  after  puberty ;  a  further  consideration  of  this  subject  is  not 
within  the  purview  of  this  work,  but  the  study  of  certain  changes  in 
the  mucous  membrane  of  the  uterine  canal,  which,  it  is  held,  take 


150  OVULATION    AND    MENSTRUATION. 

place  during  the  menstrual  flow,  is  of  the  greatest  practical  im- 
portance. 

The  late  Dr.  Tyler  Smith  was,  I  believe,  the  first  to  call  attention 
to  the  disintegration,  or  throwing  off,  of  the  mucous  membrane  from 
the  canal  at  the  time  of  menstruation.  His  observations  were  limited ; 
but  in  one  instance,  where  the  female  had  died  during  the  flow,  he 
was  aided  in  the  examination  bj  Mr.  Handheld  Jones,  and  not  a 
trace  of  the  epithelium  or  utricular  glands  could  be  detected  hj  aid 
of  the  microscope.  That  this  change  does  take  place  has  been  con- 
firmed by  the  more  recent  observations  of  Drs.  Farre,  Williams,  and 
Aveling,  of  England.  Dr.  Barnsfather,  of  Cincinnati,  has  also  pre- 
sented the  result  of  his  investigations  into  the  microscopic  appearances 
of  the  menstrual  blood.  He  states  that  in  every  instance  under  ob- 
servation, exfoliation  of  the  mucous  membrane  took  place,  even  from 
those  in  health.  Dr.  Engelman,^  of  St.  Louis,  on  the  contrary,  claims 
that  the  mucous  membrane  becomes  only  thickened  with  the  men- 
strual congestion,  and  regains  its  natural  condition  when  the  flow 
ceases. 

Dr.  Williams^  regards  the  menstrual  flow  as  a  process  not  complete 
in  itself,  but  only  the  last  stage  in  a  cycle  Avhich  begins  at  the  cessa- 
tion of  one  menstrual  epoch,  and,  passing  through  the  "  developmental 
changes"  of  the  lining  membrane  of  the  uterus,  ends  with  the  close  of 
the  following  period.  That  there  is  no  interval  of  uterine  rest,  but 
that  the  nearest  approach  to  this  condition  is  during  the  bleeding, 
when  the  mucous  membrane  is  undergoing  fatty  degeneration  and 
disintegration.  Even  while  the  membrane  is  yet  being  thrown  off, 
the  subjacent  muscular  wall  is  in  a  state  of  active  preparation  for  the 
formation  of  a  new  mucous  membrane,  so  that  there  is,  strictly  speaking, 
no  such  thing  as  a  period  of  uterine  inactivity.  The  lining  membrane 
of  the  uterine  cavity  is  generally  thrown  off  cell  by  cell,  the  process 
beginning  always  just  within  the  internal  os,  gradually  extending  to 
the  fundus,  and  at  the  same  time  towards  the  muscular  wall.  This 
process  is  completed,  with  many,  in  three  or  four  days,  but  with 
some,  seven  or  eight  days  are  necessary  before  the  whole  membrane 
is  removed.  The  disintegration  not  only  affects  the  tissues  about  the 
bloodvessels,  but  the  coats  of  the  vessels  also,  so  that  these  are 
opened,  and  hemorrhage  takes  place  from  them.     This,  he  states,  is 

'  American  Journal  of  Obstetrics,  May,  1875. 

2  On  the  Structure  of  the  Mucous  Membrane  of  the  Uterus,  and  its  Periodical 
Changes.  By  John  Williams,  M.D.,  etc.  Obstetrical  Journal  of  Great  Britain 
and  Ireland,  March,  1875. 


UTERINE    MUCOUS    MEMBRANE.  151 

Aveling's  "  denidation."  It  is  also  claimed  that  while  this  destruc- 
tive process  is  going  on,  active  proliferation  is  taking  place  in  the 
muscular  tissue  beneath  the  mucous  membrane  as  it  is  thrown  off'. 
That  the  formation  of  the  new  membrane  also  begins  immediately 
within  the  inner  orifice,  advances  towards  the  fundus,  and  is  completed 
at  the  end  of  a  week.  It  is  affirmed  that  this  membrane  is  formed 
from  the  wall  of  the  uterus,  there  being  no  cellular  or  submucous 
tissue,  its  "muscular  fibres  producing  the  fusiform  cells,  the  connective 
tissue  the  round  cells,  and  the  groups  of  round  cells,  in  the  meshes 
formed  by  the  muscular  bundles,  the  granular  epithelium."  The  whole 
membrane  is  found  lined  by  columnar  epithelium  at  the  end  of  a  week, 
by  extension,  it  is  supposed,  from  the  epithelial  lining  of  the  cervix ; 
and,  probably,  the  epithelium  of  the  tubular  glands  of  the  body  contri- 
bute also  to  its  formation.  "An  abrupt  distinction  between  the  mucous 
membrane  and  the  muscular  wall  appears  first  near  the  cervix,  about 
the  tenth  day  after  the  cessation  of  the  catamenial  flow,  and  it  gradu- 
ally extends  towards  the  fundus,  which  is  reached  a  little  before  the 
bleeding  time.  At  this  time,  the  membrane  has  reached  the  highest 
degree  of  development  attainable  by  it  in  the  unimpregnated  uterus, 
and  is  in  a  fit  condition  to  receive  the  impregnated  ovum."  This 
stage  he  designates  as  Aveling's  "nidation."  He  claims  that  "men- 
struation, then,  is  neither  congestion  nor  a  species  of  erection,  but  a 
molecular  disintegration  of  the  mucous  membrane  of  the  body  of  the 
uterus,  followed  by  hemorrhage."  The  increased  flow  of  blood  to  the 
uterus  "  is  determined,  then,  by  the  active  processes  going  on  in  the 
organ,  and  is  in  no  way  allied  to  congestion."  The  maximum  is 
reached  just  before  the  menstrual  flow  appears.  "  When  fatty  de- 
generation sets  in  the  flow  is  suddenly  reduced,  when  proliferation 
sets  in  actively  again,  the  blood  supply  is  increased,  and  continues 
gradually  to  be  increased  until  the  membrane  has  attained  its  full 
development,  when  the  supply  is  again  suddenly  diminished,  and  the 
changes  described  take  place,  unless  conception  shall  have  occurred." 
Dr.  Aveling^  defines  "  Nidation"  to  be  the  periodical  formation  of 
the  membrane  lining  the  body  of  the  uterus,  which  is  developed  during 
the  inter-menstrual  period.  He  states  "  without  an  ov^ary,  there  can 
be  no  reproductive  life,  and  without  this  life  there  can  be  no  nidation. 
So  far,  therefore,  nidation  is  dependent  upon  ovulation  for  its  being. 
Sexual  life,  however,  once  established,  the  existence  and  periodicity 

1  On  Nidation  in  the  Human  Female,  by  J.  H.  Areling,  M.D.,  etc.,  Obstetrical 
Journal  of  Great  Britain  and  Ireland,  July,  1874. 


152  OVULATION    AND    MENSTRUATION. 

of  nidation  proceeds  "with  an  independence  and  individuality,  the 
actuality  of  which  is  little  appreciated."  "  Nidation  has  heen  likened 
to  gestation.  Denidation  may  be  compared  Avith  parturition.  The 
nidal  decidua  having  reached  its  full  development,  and  no  impregnated 
ovum  having  arrived  to  demand  from  it  protection  and  sustenance,  a 
process  of  degeneration  takes  place,  its  attachments  are  loosened,  and 
it  is  expelled  by  the  contractions  of  the  uterus,  sometimes  wholly  in 
the  shape  of  a  triangular  sac,  but  more  frequently  in  minute  portions. 
How  long  this  process  occupies,  has  not  been  determined,  but  it  is 
probably  completed  during  the  menstrual  period."  "  The  act  of  de- 
nidation probably  determines  that  of  menstruation,  because  it  is  from 
the  denuded  surface  of  the  uterus,  caused  by  the  removal  of  the 
nidal  decidua,  that  the  menstrual  flow  comes."  "  The  process  of  de- 
nidation is  doubtless  very  much  assisted  by  that  of  menstruation.  By 
the  menstrual  flow,  the  debris  of  the  nidal  decidua  is  floated  and 
washed  out  of  the  uterus  and  vagina,  and  in  this  way  the  denidal  act 
is  rendered  more  prompt  and  effective." 

Dr.  Engelmann,  in  his  paper  already  referred  to,  differs  in  opinion, 
and  claims  the  deductions  drawn  by  Dr.  Williams  are  not  always 
coi-rect,  since  his  observations  were  confined  to  the  examination  of  the 
uteri  of  those  who  had  died  from  diseases  which  may  possibly  have 
affected  the  condition  of  the  uterus.  Dr.  Williams,  in  a  subsequent 
article,^  states,  "  The  theoretical  objections  to  the  view  that  the  so- 
called  mucous  membrane  of  the  uterus  is  renewed  by  proliferation  of 
the  superficial  laminae  of  the  muscular  wall,  is  based  on  the  fallacy 
of  regarding  that  wall  as  a  muscle  pure  and  simple.  I  have  pointed 
out  in  this  paper  that  it  is  much  more,  that  it  is  indeed  part  of  the 
mucous  membrane  itself,  and  that  the  terms  muscular  wall  and  mucous 
membrane,  as  they  are  generally  applied  to  the  uterus,  are  misnomers." 
He  also  contends  that  the  objections  of  Dr.  Engelmann  are  not  well 
taken,  since  his  observations  were  not  made  in  any  case  where  the 
female  had  died  during  the  menstrual  period. 

This  subject  is  yet  far  from  being  settled,  but  its  importance  merits 
the  fullest  consideration.     These  investigations  lead  in  the  right  di- 
rection, and  by  further  observation  are  destined  to  throw  light  on 
many  obscure  points  in  the  pathology  and  treatment  of  uterine  disease. 
Dr.  Tili^  has  tabulated  the  results  of  observation  in  different  parts 

'  The  Mucous  Membrane  of  the  Body  of  the  Uterus,  Obstetrical  Journal  of  Great 
Britain  and  Ireland,  Nov.  1875. 

2  On  Uterine  and  Ovarian  Inflammation,  etc.,  by  Edward  G.  Tilt,  M.D.,  p.  41. 


AGE    AT    PUBERTY.  153 

of  the  world,  to  show  the  age  of  first  menstruation  for  some  12,521 
women.  At  Calcutta  the  average  is  shown  to  be  12.49  ;  for  Copen- 
hagen, 16.88  ;  and  for  5218  English  women,  given  in  this  table,  from 
different  observers,  the  average  was  11.92  years.  It  is  stated  by 
the  same  author,  on  the  authority  of  Dr.  McDiarmid,  who  accom- 
panied the  Arctic  Expedition  under  Ross,  that  puberty  with  the 
Esquimaux  is  frequently  delayed  until  the  age  of  23,  and  Avith  many 
afterwards  only  a  slight  shoAv  occurs  during  the  short  summer.  The 
Aveisht  of  evidence  set  forth  in  this  table  is  conclusive  in  showing  the 
influence  of  climate  in  hastening  or  retarding  puberty.  But  my  own 
impression  is  that  the  habits  of  race,  through  which  the  nervous  system 
is  influenced,  are  the  most  important  factors  in  determining  the  time 
of  puberty,  and  that  climate,  in  itself,  has  but  little  influence.  Pri- 
vation, and  a  want  of  physical  growth,  as  a  rule  retard  the  first  ap- 
pearance of  menstruation,  while  an  undue  development  of  the  nervous 
element  always  hastens  puberty.  Civilization,  in  connection  with  a 
luxurious  mode  of  living,  undoubtedly  hastens  this  period,  and  it  will 
be  found  that  the  women  of  the  cities  menstruate  somewhat  earlier  than 
those  living  in  the  country  with  more  simple  habits  of  life. 

More  than  half  of  the  women  who  have  been  under  my  observation 
menstruated  for  the  first  time  during  the  season  of  four  months,  be- 
tween the  beginning  of  April  and  the  end  of  July.  The  explanation 
offered  is  that  the  organs  of  generation  are  in  a  more  active  state  at 
this  period  of  the  year  than  at  any  other. 

In  Table  I.  I  have   o-iven  the  aore  at  first  menstruation  for  two 

o  o 

thousand  three  hundred  and  thirty  women  treated  by  me  in  private 
practice.  They  were  from  the  better  classes,  nearly  all  natives  of 
the  country,  and  from  every  portion  of  the  United  States.  With  the 
advantage  of  so  intelligent  a  class,  I  have  been  able  to  obtain  accurate 
information  on  a  variety  of  points  which  will  be  presented  in  a  sta- 
tistical form.  I  have  unfortunately  not  obtained  the  same  information 
from  all,  so  that  the  number  of  cases  will  vary  somewhat  in  the 
different  tables.  This  has  been  due  to  inadvertence  in  recording  the 
cases,  or  from  the  patient  being  unable  to  give  the  required  informa- 
tion with  accuracy,  and  where  any  doubt  has  existed  the  case  has 
been  excluded.  When  a  patient  has  menstruated  for  the  first  time 
before  or  after  the  half  year,  I  have  placed  the  age  for  puberty  at  the 
nearest  complete  year,  and  to  test  the  accuracy  of  this  plan,  I  have 
added  together  with  the  even  year  the  additional  odd  month  for 
several  hundred  cases.  For  so  large  a  number  the  result  has  been 
the  same  for  all  practical  purposes,  and  as  but  a  slight  difference  was 


154 


OVULATIOiSr    AXD    MEXSTRUATIO^T. 


found    betTveen  the    average  obtained  by  either  method,  the  plan 
followed  was  adopted  as  a  saving  of  labor. 


Table  I. 

— Regularity 

of  Menstruati 

on 

Age  at  first  menstruation 

1 
10.     11.     12. 

13. 

1 

1 
14.    15. 

16. 

35 
f 

■ 

17. 

11 

7 
8 

I       1 
18.  19.  20. 

2    2.. 
5    1      . 

3'  2 :  . 

21. 

•23. 

5 

0  a 

c  .3 

=  1 

i  S 
>  = 

•2    1 

icS    , 

<■  °  I 

Unmarried — 
Kegiilar  from  the  first 
"           afterwards 
''           never 

1  '     7      21 

-.1     6  ,     8 

2  :   1    12 

5.T      8.1  !  43 
16      18      11 
9      14        8 

262 
81 
66 

14.16 
14.31 
14.36 

Total 

3      14      41  1  80    117      62    51 

26    10    5      .. 

409 

14.21 

Sterile— 
Kegulur  from  the  first 
"           afterwards 
"           never 

3 
2 

11 

7 

1 

46 
20 
6 

101 '  109'  68 
3fi|     26|  21 
13:     1.5    15 

1           1 

50    33     5;     6 

22     8     4     4 

s;    5    5|  .. 
so    -tfii  IJ.:  in 

— 

■• 

'i 

432 
144 

69 

14.18 

14.18 
14.6S 

Toial 

0      19      72  ,  144    l.'50!l04 

645 

14.23 

!      !      !           1     1    1     1    i 

Fr^itfal— 
Kegular  from  the  first 
''            afterwards 
"           never 

8 
3 

33 
11 
4 

124    161    23.5  174  121 
32      42      49,  40    23 
5      10      20      Bj  13 

70    24 
21    11 
5      2 

3 

2 

2 

1 

1 

— 

976 

235 

65 

L276 

14  22 
14.2.^ 
14.. 35 

Total 

11 

48 

161 

213 

324  220il57|  96,  37 

5 1 3  1 

14.23  1 

Total  on  all  women — 
Eegular  from  the  first     12      51 
''           afterwards  j     5      24 
"           never 2       6 

19l!  317    440  285  206  114    Slj  111  2 

60      88      93    72:  54|  3fi    20      7|  1 
23'     32     49    29[  28    IS;  10     2'   . . 

1 

i 

1670 
460 
200 

14.20 
14.23 
14.42 

1 

Total 

19   .    .SI    i   274'   4.'^7i   .nPI  lf!Rfi,9.,Sfi!lfifi!   fil  1   20.    S    ;    1    i    1 

2330 

14.23  i 

I 

1 

The  average  age  at  first  menstruation,  as  given  in  the  above  table, 
for  all  women  is  14.23  years.  It  will  be  noted  that  there  existed  no 
material  difference  between  the  average  given  for  the  unmarried, 
sterile,  or  fruitful.  But  on  comparing  these  results  with  those  given 
in  Table  YIII.,  where  the  relation  of  puberty  to  regularity  and  pain 
of  menstruation  is  shown,  a  slight  discrepancy  will  be  detected.  This 
is  due  to  the  fact  that  a  number  of  cases  which  were  chiefly  surgical 
in  character,  were  included  in  Table  I.,  and  excluded  by  accident  from 
the  other.  The  average  as  shown  in  Table  YIII.  for  the  unmarried  is 
nearly  the  same.  But  the  sterile  were  found  to  have  first  menstruated 
at  a  liitle  earlier  period,  and  the  fruitful  about  twentj^-six  days  sooner 
than  the  average  given  above.  With  this  explanation,  we  may  accept 
the  average  of  14.14  years  as  the  proper  one  for  those  women  Avho 
suffered  in  after  life  from  uterine  disease,  while  a  mean  between  the 
two  averages  would  be  14.18,  or  fourteen  years  and  sixty-five  days. 


AGE    AT    FIRST    MENSTRUATION . 


155 


The  earliest  age  at  which  puberty  has  occurred  under  my  observa- 
tion has  been  ten  years,  and  the  latest  twenty-tliree  years.  By 
reference  to  Table  I.,  it  will  be  seen  that  nineteen  females  menstruated 
for  the  first  time  at  this  early  age.  That  the  flow  was  not  an  acci- 
dental bleeding  is  shoAvn  by  twelve  of  these  having  remained  regular 
from  that  time,  and  five  became  so  within  a  year,  while  the  remain- 
ing two  cases  were  never  regular.  The  connection  between  the  age 
of  puberty  and  childbearing  will  be  referred  to  hereafter.  As  a 
curious  circumstance,  however,  I  may  state  that  the  eleven  fruitful 
women  who  menstruated  for  the  first  time  at  ten  years  of  age  were 
impregnated  fifty-nine  times,  and  that  the  average  number  of  children 
borne  by  these  was  greater  than  for  those  who  commenced  to  men- 
struate at  any  other  year,  while  their  average  age  of  marriage  Avas 
■18.25  years.  The  ages  of  ten  and  nineteen  bear  the  closest  relation 
to  each  other  in  reference  to  first  menstruations,  and  are  almost  the 
extremes,  since  the  table  shows  that  the  likelihood  of  development 
after  the  latter  age  is  very  small,  giving  but  three  instances  of 
puberty  at  twenty,  and  but  one  each  for  the  age  of  twenty-one  and 
twenty-three  years. 


Table  II Average  Menstrual  Age. 


Age  at  first  men- >,„      ,,    i    .c, 
sti-uation \           : 

1.3. 

14.    j    15. 

16. 

17. 

18. 

19. 

20.     21.  j  23. 

_:  1 
s  1 

"i  i 
E-     1 

Uumarried 3  j   li        41 

Percentage....   0.71  3.43   10.03 

80        117 
19.57     28.61 

62 

15.15 

51 

12.47 

26 

6.35 

10 

2.44 

5 

1.22 

409, 
645 

Sterile 

5 

0.77 

19 

2.94 

72        144 

11.16     22.32 

150 

23.25 

104 

16.12 

80 

12.40 

46 

7-13 

14 

2.17 

10 

1-55 

.. 

1 

0.15 

Percentage  .... 

i 
Frnitfnl '  11 

Percentage o.Se 

1 

4S 
3.76 

161 
12.61 

213 
16.69 

324 
25-39 

220 

17.24 

157 
12.30 

96 
7-52 

37 
2.89 

5 
0.39 

3 
0.23 

1      .. 
0.07 

'276 

Total  for  each,  year 
Percentage 

19 
0.81 

81 
3-47 

274 
11.76 

437 
18.76 

591 
25.36 

383 
16.56 

288 
12.36 

168 
7.21 

61 
2.61 

20 
0.85 

3 
0.12 

1 
0.04 

1 
0.04 

2330 

In  Table  II.  is  given  the  proportion  of  unmarried,  sterile,  and  fruitful 
women,  and  also  the  percentage  on  the  total  number  of  those  who 
menstruated  for  the  first  time  at  any  given  age. 

The  proportion  menstruating  for  the  first  time  at  fourteen,  the 
nearest  even  age  to  the  general  average,  is  25.36  of  the  total  number. 
Of  those  first  menstruating  below  fourteen  years  of  age,  the  number 


156 


OVULATION    AND    MENSTRUATION. 


of  sterile  women,  in  proportion  to  the  whole  number  of  sterile,  "vvas 
greater  by  three  per  cent,  than  the  number  of  fruitful  to  their  whole 
number  ;  due  to  the  fact  that  the  number  of  sterile  women  menstruating 
at  thirteen  was  nearly  as  great  as  at  fourteen  years  of  age.  Above 
the  age  of  fourteen  there  existed  but  little  difference  in  the  relative 
proportion  of  sterile  and  fruitful  women  who  developed  late. 


Table  III Regularity  of  Menstruation. 


Regular  from  the  first , 
Percentage  . 

Regular  afterwards 
Percentage  . 

Never  regular    .     .     , 
Percentage  . 

Total  .     .     .     . 
Percentage  . 


271 
64-37 

81 

19.23 

69 
16.38 


421 
17.20 


Sterile. 


453 
67-51 

145 
21.60 

73 


671 
27.42 


Fruitful. 


1046 

77.19 

237 
17-49 


1355 
55-37 


Total. 


1770 
72-33 

463 
18.92 

214 
8.74 


2447 


Regularity  of  Menstruation. — It  is  shoAvn  by  Table  III.  that  of 
two  thousand  four  hundred  and  forty  seven  women  72.33  per  cent, 
were  regular  from  the  beginning,  18.92  per  cent,  were  regular  after  a 
certain  time,  and  8,74  per  cent,  were  never  regular. 

The  average  length  of  time  for  all  before  becoming  regular  Avas 
about  eighteen  months  and  three  days  after  the  first  appearance  of 
menstruation. 

This  table  shows  the  influence  of  marriage  in  bringing  about  regu- 
larity of  the  menstrual  flow,  since  the  proportion  of  the  sterile  who 
were  never  regular,  is  smaller  than  that  for  the  unmarried  women.  It 
shows,  also,  the  effect  of  pregnancy  as  being  even  more  decided,  since 
a  large  proportion  of  the  fruitful  women  could  only  have  become  regu- 
lar after  child-birth. 

The  total  number  in  Table  III.  is  made  up  of  those  under  my  care 
of  whom  I  had  a  complete  record.  This  number,  with  the  relative 
proportion  there  given,  of  the  unmarried,  sterile,  and  fruitful  Avomen, 
will  be  used  hereafter  as  the  standard  for  comparison  as  to  the  liability 
of  either  class  to  any  special  disease. 

There  is  given  in  Table  IV.,  for  each  year  of  first  menstruation,  the 
proportion  of  those  Avho  were  regular  from  the  first  shoAV,  those  regu- 


PAIN    DURING    MENSTRUATION, 


157 


Tablk  IV — Regularity  of  3Tenstr nation  as  to  Age. 


Menstrual  ago  .. . 

10.  !  11. 

12. 

l.S. 

14. 

15. 

16. 

17. 

18. 

19. 

20. 

21. 

23. 

Total. 

Kegular  from  the 
first 

12  1  51 

191 

11.40 

CO 
13.04 

23 

11.50 

317 
18. 98 

88 
19.13 

32 
16.00 

449 

26.88 

93 

20.21 

49 
24.50 

285 
17.06 

72 
15.65 

29 
14.50 

206 
12.33 

54 
"•73 

23 
14.00 

114 

6.82 

36 
7.82 

18 
9.00 

31 

i.8s 

20 
4-34 

10 
S.oo 

11 

0.65 

7 
1-52 

2 

1. 00 

2 

0.12 

1 
0.21 

1 
0.06 

1 

0.50 

1670 
71.26 

469 
19.71 

200 
8.59 

Percentage.. 
Regular  after- 

0.71 

5 

1.08 

2 

1. 00 

3-°5 

24 
5.21 

6 
3.00 

Porcentage.. 

Xever  rogular.. . 
Percentage. . 

Total      for    each 

19 

SI 

274 

437 

591        386 

2S8 

168 

61 

20 

3 

1 

1 

2330 

lar  after  a  certain  time,  and  those  who  were  never  regular.  This 
Table  is  of  more  interest  as  a  part  of  the  history  of  menstruation  than 
for  any  practical  deduction  to  be  drawn  from  it  other  than  of  a  nega- 
tive character.  It  shows,  with  but  a  variation  of  two  or  three  per  cent., 
that  about  the  same  proportion  are  regular  or  irregular  for  any  one 
year.  The  proportion  of  those  who  were  regular  and  menstruated 
for  the  first  time,  either  above  or  below  the  average  age  of  puberty, 
is  about  the  same  ;  and  the  same  is  true  of  those  who  became  regular 
afterwards.  But  for  the  class  who  were  never  regular,  the  propor- 
tion is  12.50  per  cent,  greater  for  those  menstruating  above  the  average 
age  of  puberty  than  below  it,  showing  that  a  larger  proportion  of  those 
who  Avere  never  regular  menstruated  for  the  first  time  late,  or  above 
the  averao;e  ao;e. 

It  is  indicated  by  Table  V.  that  in  a  state  of  health,  menstruation 
should  be  free  from  pain.     We   shall  see  hereafter  that  pain,  in  the 


Table  Y — Condition  of  Pain  during  Menstruation. 


Number  of  Cases. 
(^With perceiituye  0/ each  condition.) 

With,  pain  in  the  beginning  of  the  flow 
Pei-ceutage     .... 

With  pain  during  the  flow    .... 
Percentage     .... 

Free  from  pain 

Percentage     .... 

Unmarried. 

Sterile. 

Fraitful. 

Total. 

57 
19.19 

84 
28.57 

209 
13-17 

135 

45-45 

151 
51-36 

311 
19.59 

105 
35-35 

59 
20.06 

ion7 
67.23 

297 
13-63 

294 
13-49 

1587 
72.90 

Total 

350 

597          1231 

2178 

158  OVTTLATIOlSr    AND    MENSTKUATION. 

beginning  of  the  flow,  at  puberty  is  not,  as  a  rule,  a  symptom  of  disease 
but  of  a  form  of  congenital  flexure  of  the  uterine  neck. 

We  may  assume,  therefore,  from  a  total  of  two  thousand  one  hun- 
dred and  seventy  eight  women,  that  but  13.49  per  cent,  gave  indica- 
tion at  puberty  of  a  condition  which,  in  after  life,  would  render  the 
individuals  more  liable  to  disease.  We  shall  see  when  considering 
the  different  forms  of  flexures,  that  the  character  of  the  pain  at  this 
period  of  life  is  sometimes  an  indication  of  a  condition  which  may 
necessitate  a  resort  to  local  treatment,  even  at  so  early  an  age.  I 
cannot  now  enter  on  this  subject  at  greater  length  without  repetition 
hereafter.  But  I  would  call  the  attention  of  the  reader  to  the  fact, 
pointed  out  by  Table  V.,  that  more  than  half  of  all  the  women,  who  at 
puberty  suft'ered  pain  during  the  flow,  were  sterile  in  after  life.  If 
we  exclude  the  unmarried  (since  we  cannot  know  the  proportion  of 
those  who  would  be  sterile),  we  will  find  that  of  all  married  women, 
who  at  puberty  suft'ered  pain  during  the  flow,  over  71  per  cent,  were 
sterile. 

Table  VI.  is  intended  to  give  the  proportion  of  cases  with  pain,  at 
the  beginning  of  and  during  the  flow,  and  those  free  from  it,  for  each 
menstrual  age,  in  connection  with  regularity;  and  the  averages  are 
taken  on  the  total  number  of  each  condition  as  to  regularity. 

Table  VII.  also  gives  the  proportion  who  suffered  pain,  or  who 
were  free  from  it,  in  connection  with  the  degree  of  regularity,  but  the 
averages  are  taken  on  the  total  number  menstruating  for  each  year, 
and  not  on  the  whole  number  under  observation. 

These  tables  seem  to  indicate  that  menstruation,  when  the  flow  is 
regular,  is  less  painful  when  the  development  occurs  after  fourteen 
than  when  it  takes  place  before  that  age.  But  for  those  who  were 
never  regular,  a  larger  proportion  suffered  when  puberty  took  place 
after  the  average  age.  Without  reference  to  regularity,  it  is  shown 
in  Table  VII.,  by  the  percentages  for  each  menstrual  year,  that  the 
proportion  of  those  who  were  free  from  pain  is  decidedly  greater 
when  puberty  took  place  above  the  average  age.  Over  seventy-five 
per  cent,  of  all  the  women  (sep  Table  VII.)  were  regular  and  free 
from  pain,  while  fifteen  per  cent,  more  suffered  from  pain,  who  were 
never  regular. 

When  pain  e'xisted  only  at  the  beginning  of  the  flow,  it  is  indicated 
by  Table  VIII.,  that  all  women  menstruate  for  tlie  first  time  at  an 
earlier  age  than  under  any  other  condition.  Those  who  were  free 
from  pain  developed  a  little  later  in  life,  and  where  the  dysmenorrhoea 
continued  during  the   period,  puberty  was  delayed  about  a  month 


PAIN    DURING    MENSTRUATION. 


159 


■ai«(I 
■  Oil 


■3utjn(i 


•,.ntn 


ox 


•Snuna 


•Snin 


•niisd 


•SuUllQ 


•Siitu 


•ni'Ed 

■    OJJ 


•SutJUd 


•ared 
'  ox 


•3uiiti(i 


•Sntu 


'  ox 


■3aunQ 


•Sntn 


0  :3 


Oi  \0         C^    r^       rH 


^  U-)     5^  q      lo  ^ 


Orj     N  C/:,   CO  to   ^ 

-C  OO         CO    ID       C^ 


=0     N  "-■ 


i-H    "         O  "         «    0\ 


to   •?      "O  ^ 


t,>o       c^  in      eq  ^ 


a^ 


^f=^ 


•IBJOX 


•Dt'Bd 

■    OiJ 


SnunQ 


eo  f-t 


a     ::: 


•Snin        cj 


•Qiud 


•Ui'Bd 

■  OK 


•niBd 

■    OK 


•Ui'Bd 

'  OK 


■SnuTid 


■Sniu 
-ui3ag 


tM    ".        rH    1" 


^ 

o 

o 





rH 

s 

o 

eo 

-1< 

o 

•UIBd 

'  OK 


'Suiiiid 


e^    M         r-i 


•Sniu 
-uiSag         g       :   : 


•niBd 
■  OK 

•SuunQ 

(MM 

0 

lO  >o 

•Snin 
-aiSag 

ro 

CD    ^ 

M    "? 

•ni'Ed 
'  OK 


■3niiiici 


•Snin 
-uiSag 


bj        ^ 


160 


OVULATION    AND    MENSTRUATION. 


-? 


s 


8 


S 


Hi 


^ 

0 

'S 

^ 

■mvd  ojti 

cc  to  «o 

t-  coto 
CO  oq 

t^  "^p 

S4 

CO   0 

'^'  A 

'"' 

rH     p. 

o 

VO 

'»   r-. 

tv 

ro 

-f 

„ 

CT 

■* 

lO 

•Suijn(j 

(M  CO      . 

lO  w  ■* 

t-  •*  rH 

CO   e. 

(M  ";> 

>o  4 

" 

N 

^ 

^ 

m 

VO 

f> 

■SninuiSag 

COrH  rt< 

t~  rH  rH 

,-1  '^••-1 

CO   „■ 

CO  VO 

d 

"*  cj 

u- 

„ 

^ 

ir 

■nj'Bd  0^ 

CO  t^  CD 

CO  o;  -ti 

CO    o 

C^  VO 

IM    <7 

CO    t>.             VO 

^    ?. 

O 

N 

00 

r->.            ^ 

Tt* 

■SuutiQ 

-f  t-  CO 

s^-^ 

rH  CO  CO 

CO  '■; 

•^     N 

o  ■:: 

'-i 

•O 

„ 

VO 

00 

CO 

•SmaniSag 

IQ  M  i-H 

r-OCD 

c^-^" 

CO    4        rH     ,:. 

o  ■: 

«  J- 

■^ 

N 

" 

rr 

t^ 

00 

oo 

•ui-Ed  ox 

o  c~o 

CO  OS  o 

gS^ 

H*      J 

«5    ". 

g 'f 

'"' 

<^  c^          vb 

■* 

IM  S 

VO 

Ov 

^ 

CC 

•Snuna 

Ir~-J<  rl 

CO  -*  o 

Ol  CO  CO 

^    ro       rH    i/i 

o;    u 

s  [^ 

" 

" 

« 

" 

>o 

r^ 

oo 

"2 

•3uiuniSea 

too  r-. 

-J"  00^ 

rf   CO  (N 

^   o 

'  ^i 

tr^    v' 

COo 

r 

„ 

O 

0 

•ni-Bd  o>i 

CO-*  o 

-V  o^ 

rH  CO 

o  t- 

C  ifi 

"^ 

VO 

„ 

CO 

„ 

„ 

« 

•J^nutiQ 

to  coeq 

CI  CO  rH 

e•^    -iM 

eq  0 

^      M 

CO    r 

1^ 

•SnmniSsg 

rt*      •  rH 

lOCO  IM 

Tf  CO      ■ 

CO  c» 

CO   ■<> 

CO    =^ 

CO    „ 

" 

" 

" 

1-              0 

0 

jj 

•niBd  0^ 

CO      ;r-l 

to  (M      . 

o  cs  o 

§2 

vo" 

t- 

to  f^ 

VO 

„ 

VO 

0 

O 

•Suuno; 

rH  (M  rH 

(M        .rH 

Ttl      .      . 

t,  c< 

[:: 



— 

" 

" 

N 

" 

-a-                M 

„ 

•SuiuniSeg 

(N(M      ■ 

Tl<  rH      • 

-*  r-l       • 

o  t^    •*  v^ 

0 

8 

VO 

u- 

•ni'Bd  0^ 

rH      -rH 

(M  rH  rH 

<a  (N    • 

"8 

(M  ^ 

CO    " 

o 

VO 

CO 

•Snjjtid 

2 

■SnmntSaa 

-  :  : 

-  :  : 

:  :- 

c 

r-(    '^ 

CO    "^ 

0 

b 

C3 

m 

c« 

p 

^ 

_c 

«  "Z 

13  ^ 

to 

a 

F 

11 

o  c:  - 

a  s^ 

a  s  5 

te  » 
0       t   -0 

a 

CIS 

1  i;  ts  1 

o;  (s 

ttc 

J            a 

"S  rt^ ;: 

d  3   '^ 

lis 

«  i^ 

fcJ: 

<M 

■Cfl   S   c 

1    O   3   o 

t  ^^ 

3 

o 

c3  (i>  c   a 

-        i  !X  bfj  > 

£  if.  M  > 

13  c  0)  » 

5  tc 

ic 

i 

<>            a 

£««<! 

,       X  «  W  » 

•3«Kg 

i         s« 

Ph 

« 

H 

Eh 

•n 

H 

tJ 

in 

REGULARITY  AND  PAIN  OF  MENSTRUATION. 


161 


■ea^jnaaiaj 


•I'loj, 


•ntBd  o^ 


•3uijnQ 


■SninniSdg 


O  r~  c-l  ffJ  o  t^ 


cc  to  -^  CC  -t'  ^^ 


t^  r-.  rH  t~r-i 


c»-^«co  u-^tc—  c^oso 

oc^co  c^-fro  -^--^o 


;  "  "  C5  c<  >-H  t~  ~i 


•niBd  o^ 


o  "     CO  Sj    <»  2. 

{,,  n      CO  'p      nH   -«• 

C<    in       N  CO         rH    o 


•S.     t?  E;    "^ 


•nicd  ojj 


■niBd  ojj 


I-H    0        ,.^0 


■ni'Bd  0*^ 


C^  ^  C^  CO  ^      •  CO  iC 


■SnutiQ 


•SninTiiSag 


•uiBd  ox; 


eCn-l-l  M.(M  p,OrH 


•SnuUQ 


1—  oi     .  M     .  ^ 


•SuiumSag 


■atud  ov; 


•Snund 


•SnianiJJaa 


•ured  ox; 


■SniJtiQ 


■^ninuiSag 


r;  CO  (^  r-  ai  CO 

CI  Or-. 


Id  rt      -IM 


ClCOr-l  COr^i-H  COJlrH 


CC     "*"        O     ^ 


— .-rco  t^O)-f  c~.  coi 

d  c»  c;  1-^  r 


■*    •  .-1  c:  c^  CI  t^  cq . 


is 
1  its 

S  to 

«»; 

S« 

^?. 


d  o 

t  e 


If 

■3  A. 


ri     3 

0 

^S 

C^ 

2 

ro 

r^ 

11 


1G2 


OVULATIOX    AXD    ME^:  STRU  ATIOX  . 


« 


Si 


^ 


R^ 


I— I 
> 


•^■Bnrnmg 

2? 

I— 1 

X 

t^ 

X 

■ 

— 

^ 

— 

T1 

^          : 

_ 

t~ 

^^ 

j^ 

r^ 

--- 

_^ 

c; 

^ 

:C 

^ 

o 

?— ! 

CO 

c:i 

'injnnjj 

T-l 

~.* 

_4 

o 

-tT 

C-l 

"* 

h9 

C_I 

_^ 

^- 

!— ! 

•< 

O 

t^ 

■ 

X 

^ 

r1 

I— 

X 

ir' 

^ 

o 

i^ 

'1 

,_ 

?1 

r- 

■en^aiS 

rH 

-*■ 

rA 

r— '. 

ct 

ir: 

I— 1 

t^ 

CO 

o 

CC 

CI 

£■ 

rH 

'1       ! 

o 

•paijj-EniTij^     j 

-j? 

-^ 

c5 

^       i 

CC 

^ 

• 

' 

^ 

^       1 

r-! 

i^ 

■^ 

^ 

2 

X 

C5 

^ 

•I^ioi 

-j: 

^ 

I—- 

-*" 

I-I 

^ 

■< 

'— 

■"■ 

^^ 

I— 1 

o 

c-l 

— 

X 

Oi 

(M 

cc 

l^ 

-*       1 

^3 

CO 

tJ 

■tUT^Tiiij; 

■^' 

"* 

~r^ 

i^ 

•i- 

s 

r— ) 

r^ 

a 

Pi 

^ 

.^ 

-ji 

Bi 

, 

5 

-^ 

— 

, 

■^ 

^ 

•8IIJ813 

S 

^ 

M 

-t 

c- 

— ■ 

fi 

-r-' 

H 

1— i 

^T 

T^ 

^ 

^ 

i~ 

C-. 

ir^ 

•paujBniTi^ 

O 

ir^ 

oo 

2 

H 

3          i 

I— 1 
o 

CO 
I-I 

~. 

-f 

t^ 

— 

X 

Tl 

X 

»rj 

cc 

'^ 

cq 

■mox 

c^ 

-f 

?i 

~^          ^ 

CO 

'^ 

o 

^■ 

— 

1-1 

pj 

< 

'^1 

^ 

1 

-r 

, 

— f- 

^1 

71 

< 

•injnnjj: 

!M 

i-i 

S 

'^ 

o 

CO 

1-1 

I— i 

1— ! 

I— I 

t-;^ 

?1 

t- 

Ci 

< 

^ 

•aiuaig 

l-H 

CO 

-* 
^ 

zf 

CO 

-r 

& 

S 

- 

-w 

m 

X 

K 

,— 

?1 

i^ 

f— , 

^• 

Oi 

M 

•paijiBtnnj^ 

i-i 

-* 

cq 

^ 

^ 

o 

1* 

I— i 

t-i 

I— 1 

^. 

■^ 

CT 

■z. 

:; 

CO 

X 
O 

E^ 

•pjox 

:; 

5 

_j; 

^i 

-^ 

-* 

2 

^- 

r~ 

— ^ 

1— ' 

£ 

•IBj^nua 

CO 

M 

-r 

X 

X 

CO 
CI 

0^1 

c; 

CO 

O 
« 

es 

■< 

h3 

r-( 

I— 1 

CO 

o 

t^ 

"M 

i-"^ 

t- 

c 

-* 

•aiua?3 

CI 

l-H 

I— I 

-** 

ji 

^ 

^ 

-t 

I— 1 

r-H 

I— 1 

r-l 

& 

g 

1^ 

— 

^j 

c; 

"J 

Ci 

o 

t~ 

« 

•psuiBamj^ 

X 

■^ 

r— f 

I-I 

rH 

,~^ 

_^ 

^WWs 

>> 

^-^ 

^ 

, 

^ 

rO 

5 

^ 

— 

^ 

, 

n 

c    • 

o 

p; 

»— ^  . 

"X 

^ 

— 

to 

<"  to 

»-M 

? 

»— ( 

*— 

»— ' 

, 

rt 

tD 

o 

to 

o 
to 

O 

to 

U 

to    - 
ci 

o    • 
to 

c 
to 

u 
o 

-2  s 

eS 

r^     S^ 

ci 

p—    .^ 

c3 

«-i 

S  ^ 

i. 

^  ri 

I-, 

ei 

p 

o 

^ 

<j 

^ 

<5 

^ 

< 

E-i 

AVERAGE  DURATION  OF  MEXSTRU ATIOX.        163 

longer,  on  an  average,  than  in  those  cases  in  which  pain  occurred 
only  at  the  beginning.  The  average  on  the  total  number  Avas  14.14 
years,  and  approached  nearest  to  that  found  where  the  flow  had  been 
free  from  pain. 

The  average  age  for  the  fruitful  women,  who  were  regular  from 
the  first  but  with  pain  in  the  beginning  of  the  flow,  was  found  to  be 
earlier  than  that  of  the  sterile  or  unmarried,  under  either  condition, 
that  is,  as  to  the  existence  or  absence  of  pain.  The  reverse,  however, 
is  true  in  comparison  Avith  the  sterile,  Avhere  menstruation  became 
regular  afterwards,  since  in  this  condition  puberty  was  delayed  with 
the  fruitful  women.  The  number  of  those  who  Avere  never  regular  is 
almost  too  small  to  furnish  any  definite  data,  yet  the  average  age  for 
the  fruitful  is  earlier  than  for  either  the  sterile  or  unmarried  Avomen. 
On  the  general  average  the  age  of  puberty,  under  all  conditions,  as 
to  pain,  is  also  at  the  earliest  date  for  those  who  were  fruitful  in  after 
life. 

Unfortunately,  Ave  have  no  data  to  show  the  average  age  at  puberty 
of  those  Avho  Avere  healthy  in  after  life.  Until  this  is  knoAA^n,  all 
comparison  must  be.  based  on  the  different  degrees  of  liability  to 
disease,  if  the  age  at  puberty  has  any  relation  to  the  subsequent 
state  of  health.  We  have  already  seen  that  the  average  age  at 
puberty,  as  taken  from  the  observations  cited  by  Dr.  Tilt,  is  14.92 
years.  The  results  of  my  observations  seem  to  show  that  women  in 
this  country  develop  at  an  earlier  age  than  in  England.  But  before 
we  can  arriA^e  at  any  definite  conclusion,  the  comparison  must  be 
made  between  those  of  corresponding  stations  in  life.  I  assume,  in 
the  absence  of  any  evidence  to  the  contrary,  that  the  observations  in 
England  were  made  upon  the  same  class  of  women  as  are  treated  in 
the  public  institutions  of  this  country.  If  so,  any  comparison  would 
lead  to  error,  since  I  am  convinced  that  careful  records  Avould  show 
that  the  average  for  the  same  class  of  patients  in  this  country  would 
approximate  nearer  to  the  English  average  than  to  the  one  I  have 
giA'-en.  If  it  be  shoAvn  that  the  average  age  at  puberty,  for  the  better 
classes  of  England,  is  so  much  later  than  in  this  country,  it  would 
indicate  that  a  larger  proportion  of  our  women  are  sterile  ;  or,  Avhen 
fruitful,  more  liable  to  disease  and  early  loss  of  youth. 

The  average  duration  of  menstruation  at  puberty  is  shoAvn  by  Table 
IX.  to  be,  for  all  women,  4.82  days.  For  the  class  of  cases  fruitful  in 
after  life,  the  duration  was  4.91  days,  and  of  greater  length  than  the 
general  average   found  for  either  the  unmarried  or  sterile.      The 


164 


OVCLATION  AND  MENSTRUATION. 


•ni'Bd 
ok 


•3niTi 


•ni'Bd 


Snuno; 


•Snin 


•ni'Bd 

ok 


■SnuTig; 


■Stiitj 
-uiSeg 


•ni'Bd         eq     eq 

ojsr 


■Snin 


•ni'Bd 
OH 


•SnuTLd 


•i^uin 
-aiSag 


•ni'Bd 
ON 


•Snund 


■Sum 


C3  f^ 


'V  f'  i 


■pouaiJiunj]^ 


(M 

1^ 

•^ 

^ 

^ 

CO 

O 

>a 

,ata  t'-g 

!3   O   3J   <B 


•v 

Oi 

•* 

to 

CO 

t- 

«5 

-* 

a  " 


2  =  o  = 


lO 

„ 

-f 

(r^ 

•o 

'* 

OO 

CO 

>o 

o 

n 

>o 

S-? 


■jjj'uuiiuug 


PAIN    AND    DURATION    OF    MENSTRUATION, 


165 


1         '^ 

J, 

•pqox 

UO 

c^ 

>o 

1 
1 

s 

•niBiI 

r-l          <» 

r-t         1^ 

> 

on 

<N         ^ 

"      ^ 

°>         ^ 

;2:   -^ 

e 

E 

■o 

—'       o 

-»< 

00         -*■ 

•SnunQ 

-<<      m 

lO        o 

i> 

Ci 

03           O 

Oj 

CG 

f 

'f 

•SuTn 

m 

■O         <M 

CO         CO 

-uiSaa 

'•■'    -i; 

'-'     ^ 

'-      -i! 

=<   ^ 

e^ 

•UITld 

o 

o 

o 

:     : 

o 

i-l        o 

8 

on 

■^ 

" 

^ 

^ 

^ 

•lUT.d 

o 

o 

r-         O 

o 

o 

c^ 

OM 

-^ 

'^ 

-S< 

-1< 

o 

•ured 

:      : 

o 

g 

«         § 

8 

o.ST 

• 

er 

CO 

CO 

•uiBd 

o 

O         CO 

Tj<         C-l 

o 

t^       o: 

on: 

M 

9 

•o 

"O 

c 

■^      -i< 

CO 

o- 

•Sman(j 

:     : 

CO         CO 

■* 

CO 

-jj 

•rf 

-* 

^ 

•Sniu 

IM         O 

o 

<M        c= 

-niSag 

CO 

CO 

•uiud 

O         CO 

^  s 

?3      S 

CD      a> 

0^ 

o 

"3 

'^ 

O 

c 

"      ^- 

CO 

o 

CO 

cc 

•Suund 

lO         ■* 

CO         CO 

o 

eo 

Tfi 

CO 

>o 

CO 

Tf 

"^        co" 

T)l 

•JoTim 

o 

r-l         O 

o 

1-f        o 

o 

(M        O 

-xiiJSea 

cq 

c= 

^ 

■Ul'Ed 

CO 

(M       o 

CO         § 

e»      o 

o 

on: 

'-'      -^ 

CO 

==■   -*• 

'^      ^ 

(^ 

I^      "* 

ffj 

m 

•SuTjnQ 

CD 

cr 

OJ          CD 

Tt< 

'J' 

CO 

-* 

CO 

>c 

■^            Tit 

Tj< 

•Snin 

CO         § 

lO        o 

CD         O 

CO 

-upiag 

o 

-* 

^ 

■^         "Q 

•uiud 

CO 

o      o 

CD         O 

OxM 

CO 

"O 

^   ^ 

o 

^         ^ 

S    '^" 

^ 

•Snun(x 

t~      q 
■6 

■* 

■^      o 

^ 

l-H           O 

co' 

^ 

r-        o 

CD 

•SuTn 

o 
>o      o 

CO 

o 

O         CO 

-ni^sH 

>o 

'"'      ^" 

■^         ■* 

•^   ^• 

d 
o 

c5 

a 
o 

=2  : 

d 

d 

o 

•2   ■ 

rt 

o 

J3     • 

c 

c 

o 

d 

,d 

d    • 

.2?. 

^^ 

"3 

d 

g 

n 

■a 
d 
o 

1?. 

id 

S 

n 

o 
,d 
ci 

i  d 

s 

d 

d 

s 

g   IS 

d.2 
o  .S 

=5  d 
s  o 

o 

0  ■ 

£ 

F 

g  J" 

•2 

o 

d  d 
o  o 

'is 

d    c3 

o 

d  d 
2.2 

<D    O 

o 

a  d 

5  2 
o  5 

1 

o 

Pi 
O 

d  a 
ft 

0    O 

o>2 

I- 

d 

umbe 
of  llo 
engtU 
each 

(P.2 

d  3  S  » 

be'-" 
S  .2 

umbe 
of  flo 
englh 
each 

otal  f 
flow 
eiigth 
total 

0)   o 

c 

'■5 

a     iJ 

-^ 

!?;    hj 

-^ 

S      iJ 

"^ 

H     ^ 

<< 

, 

d 

^ 

> 

V 

/ 

\ 

1  \\     \ 

^ 

■< 

«           6 

eu-iB 

nnxi 

•aiuajg 

•injjiri 

Ji 

!             •jCjBrau 

ins 

166  OYULATIOX    AST)    MENSTRUATION. 

average  for  the  sterile  was  4.T4  days,  and  for  the  unmarried  the  Aoyt 
was  of  shorter  duration  than  for  any  other  class  of  women. 

This  table  establishes  one  point  beyond  question,  viz.,  that  the  local 
condition  which  gives  rise  to  pain  exercises  a  marked  influence  in 
increasing  the  menstrual  flow  beyond  the  general  average  as  to  dura- 
tion, but  not  necessarily  as  to  quantity. 

In  the  absence  of  pain,  menstruation,  for  all  women,  lasted  for  a 
shorter  time  than  when  pain  was  present.  When  the  pain  existed 
during  the  period,  the  flow  was  prolonged  to  a  greater  length  than 
the  average  time  found  for  those  who  only  suffered  pain  at  the  begin- 
ning. The  average  length  of  the  flow,  with  pain  at  the  beginning, 
is  very  nearly  the  same  for  the  unmarried  and  fruitful,  but  is  less  for 
the  sterile.  This  circumstance  would  indicate  that  the  sterile  sufi'ered 
less  pain  than  either  the  fruitful  or  the  unmarried,  which  is,  appa- 
rently, in  contradiction  to  the  general  law.  But  we  must  look  to 
some  other  cause  exerting  an  influence  specially  on  the  condition 
which,  in  after  life,  is  to  result  in  sterility.  The  general  law  is 
proved  by  the  averages  oljtained  for  the  unmarried,  sterile,  and 
fruitful,  separately,  and  confirmed  when  taken  on  the  total  number 
collectively. 

It  will  be  noted,  also,  that  the  fimitful  women  who  suffered  pain 
during  the  flow  menstruated  for  a  longer  period  than  either  the  un- 
married or  sterile,  and,  consequently,  this  class  of  cases  must  have 
sufi'ered  more  from  dysmenorrhoea.  We  must  assume  this  result  to 
be  due  to  some  accidental  cause,  for  the  number  of  cases  is  compara- 
tively so  small  that  the  average  would  be  easily  aQ"ected  by  individual 
peculiarities. 

We  have  shown  that  painful  menstruation  is  abnormal,  and  it  has 
been  proven  that  pain  lengthens  the  duration  of  the  flow.  Therefore, 
as  the  difference  exists  chiefly  between  the  two  classes,  afterwards 
sterile  and  fruitful,  it  must  be  attributed  to  accident,  since,  if  any 
condition  exists  at  puberty  which  could  determine  the  subsequent 
sterility,  those  afterwards  fruitful  would  at  puberty  have  approached, 
by  comparison,  nearer  to  a  normal  standard. 

Table  IX.  also  gives  the  average  len2;th  of  menstruation  for  each 
year  and  for  each  condition,  as  to  pain,  for  the  unmarried,  sterile,  and 
fruitful,  as  vrell  as  for  the  total  number. 

The  only  marked  exceptions  to  the  general  laws,  already  stated, 
are  to  be  found  at  either  extreme,  and  where  the  numbers  arc  small. 
The  lonscest  duration  of  the  flow  in  the  total  numl)er  and  for  the  fruit- 


DURATION    OF    MENSTRUATION. 


167 


fill  is  found  to  be  for  those  who  menstruated  for  the  first  time  at  eleven 
years,  and  for  the  sterile  at  twelve  years  of  age. 

It  will  he  seen  by  Table  X.  that  the  flow  lasted  longer  for  the  total 
number  and  for  the  sterile  who  menstruated  for  the  first  time  below 
the  age  of  fourteen,  while  for  the  fruitful,  the  reverse  was  found. 
The  greatest  difterence  between  the  two  averages  was  found  for  the 
sterile.  When  menstruation  was  accompanied  with  pain,  and  puberty 
took  place  below  the  age  of  fourteen,  the  flow  was  longer  under  all 
conditions  than  when  free  from  pain.  The  average  on  the  total 
number  is  not  only  made  out  for  those  who  were  afterwards  sterile  or 
fruitful,  but  also  includes  those  who  remained  unmarried. 

Table  X — Giving  the  Average  Length  of  the  Flow  for  those  who  Men- 
struated for  the  first  time  above  or  helow  the  age  of  Fourteen. 


Sterile. 

Frui 

tful. 

On  the  tot 

unmurrie 

and  fr 

al  number 
d,  sterile, 
uitful. 

Above 
Fourteen. 

Below 
Fourteen. 

Above 
Fourteen. 

Below 
Fourteen. 

Above 
Fourteen. 

Below 
Fourteen. 

With,  pain  at  the  beginning 
of  the  flow 

With  pain  during  the  flow 

Free  from  pain     .... 

4.68 
4.71 
4.35 

5.09 
5.17 
4.91 

4.62 
4.57 
4.83 

5.00 
5.43 
4.76 

4.83 
4.79 
4.67 

5.12 
5.27 
4.68 

Average  length  of  menstru- 
ation on  the  total  number 

4.50 

5.01 

4.85 

4.82 

4.68 

4.80 

By  the  plan  followed  in  Table  XI.  any  change  in  the  menstrual  flow 
in  after  life  can  be  seen  from  the  average  duration  which  existed  at 
puberty. 

The  influence  exerted  by  regularity  and  pain,  in  determining  the 
length  of  the  period,  is  also  shown  for  the  unmarried,  sterile,  and 
fruitful  women  separately,  and  there  is  a  summary  for  the  total 
number. 

Two  thousand  and  eighty  women  commenced  their  menstrual  life 
with  the  flow  averaging  4.82  days,  and  it  is  shown  by  this  table  that  the 
average  in  after  life,  for  the  same  females,  was  reduced  to  4.66  days. 

The  duration  of  flow  was  shortened  in  after  life  for  all  the  unmarried 
and  sterile  women,  but  for  the  former  class  the  change  was  most 
marked.  With  the  fruitful  Avoman,  however,  the  period  became  some- 
what lengthened.     The   ireneral  law  is  noted  as  to  the  connection 


168 


OVULATION    AND    MENSTRUATION. 


s 

'&5 


»-^ 


P5 


■pOTJ9d  JO 

«3 

P- 

CO 

-* 

b- 

b- 

0 

IM 

CO 

UOT^'Bjnp  puu 
SaSTJO  IT3?0J, 

C< 

cr 

1 

a: 

0 

^ 

t> 

t 

0 

CI 

■* 

-* 

^ 

t> 

CO 

ir 

cr 

CO 

CO 

Pi 

•inj^iinj; 

<3i         C- 

s 

0 

c 

5 

CC 

C 

CO 

5 

T)< 

■< 

S 

02 

c- 

t> 

^ 

0 

-f 

c^ 

-+ 

t^ 

-t 

CO 

•eiua^S 

cr 

^ 

r-l 

0 

Tf 

c^ 

-* 

CD 
-* 

g 

CO 

^ 

t> 

CC 

^ 

a 

c^ 

y. 

0 

ir 

r- 

•psujuninxi 

t^ 

m 

r|J 

-* 

Tf 

^ 

CO 

CC 

CO 

•poij 

-od  JO  t[5Snax 

c- 

CI 

CO 
CO 

<N 

CC 

p- 

^ 

C] 

CO 

oSujaATj  puB 

^ 

-* 

■^ 

^ 

^ 

■W 

'"' 

-^ 

M< 

pi 

o 

H 

sas'BD  i^jox 

(M 

<M 

CO 

»-- 

to 

c 

to 

•Itij^mjj 

CC 

Tt 

S 

i-H 

s 

^ 

t^ 

-* 

CO 

rt 

M 

C< 

C<I 

t^ 

CC 

cr 

f. 

H 

•BTue^g 

to 

J^' 

G 

>o 

t> 

0 

•^ 

■o 

t> 

-* 

CM 

^ 

-* 

^ 

^ 

^^ 

•* 

-1H 

« 

S 

0 

m 

0 

0 

to 

•pai.ijunnj^i 

o 

C" 

^ 

0 

CO 

IT' 

3 

0 

0 

-* 

0 

■pot.t 

R 

-3d  JO  ntSiis^ 

CO 

cr 

CD 

t^ 

>o 

c 

C-3 

(M 

s 

0 

a- 

00 

M 
Eh 
6< 

^^'EI^A^'  pni3 

iT 

Tf 

■O 

0 

>o 

G<1 

-* 

rt^ 

CO 

•* 

Tt< 

saevo  xisioj, 

CD 

t^ 

0 

f~* 

cr 

CD 

•Xnj^TtiJj 

!> 

lO 

•0 

^ 

C<1 

'^ 

f 

CO 

•^ 

0 

CC 

b- 

CD 

"^ 

cr 

m 

•9Xua:)g 

5 

Cf 

-* 

(M 

2 

Tt< 

^ 

^ 

b- 

00 

•* 

'J* 

IS 

Fi3 

0 

0 

CO 

0 

cr 

t^ 

« 

•paiJj'Baiti£i 

o 

^ 

-t 

g5 

0 

0 

-+ 

P- 

-t 

»o 

-rt* 

t^ 

^ 

H 

•poa 

pj 

-ad  JO  q^Snoi; 

a- 

£ 

CC 

t^ 

c 

(T 

s 

"^ 

ir 

CO 

K 

E- 

o 

oS-e-SAv  puB 

CN 

-^ 

xt 

■"■ 

lO 

"* 

^ 

10 

-* 

-^ 

sas^a  ]E50j, 

t> 

CC 

CO 

c 

CI 

CC 

^ 

CD 

•injnnjd; 

1> 

Tt 

as 

i> 

cr 

cr 

CO 

0- 

0- 

bi 

-t 

t- 

■e]ija:)g 

o- 

^ 

0 

"O 

0- 

"* 

-t 

0 

CD 

h3 

b 

1.'- 

0 

05 

y; 

C7           CO      a 

0 

c 

CI 

•paijj'Bainxi 

t- 

0         Cf 

0     Tt 

■0 

C2 

^ 

-* 
t 

CC 

-1< 

CI 

-+ 

-1* 

<« 

o 

fe 

00' 

■3 
d 

w 

d 
0 

'3j 

.d 

^ 

^ 

to 

d 

1 

1 

a 

1    • 

1 

1 

^ 

d   : 
.2   • 

p 

d 
.2 

"S 

d 
.2 

oi 

c3 

^ 

tS 

rt     * 

p 

■H         C3 

^ 

e« 

'3 

g 

'3 

0       '. 

1 

g 

t3 

d 

0 
U 

p. 

0 

p. 

0      '. 

d 

0 

B 

^ 

a 

^ 

c 

c 

CD 

'% 

-"  It 

f- 

■$ 

a 

1 

0^ 

t- 

a_£ 

^          *»H 

M 

,a  c 

iS 

So 

,0  0 

^  r 

^ 

0 

■S  0 

e 

C! 

M^ 

H      ^ 

n 

V>,<=^ 

r' 

r 

-^  P 

H              e 

^ 

l-l,  p 

H     15 

0 

£ 

i< 

c 

'■ 

gs 

c 

a 

d  « 

5 

0     fe 

0 

C 

fc-    c 

p 

M 

0 

;. 

(P 

0 

?'= 

^ 

bo 

a 

CO 

3 

bo 

^  . 

rt 

.a 

cs 

^ 

C3 

a 

S-^ 

£ 

e 

a> 

E 

3 

a> 

0S 

t- 

0 

k 

c 

P- 

0 

> 

t^ 

•< 

^ 

<1 

^ 

-tj 

Eh 

< 

REGULARITY    OF    MENSTRUATION.  169 

between  the  degree  of  pain  and  shortened  duration  of  the  menstrual 
floAV,  when  the  averages  are  taken  on  the  total  number  for  each  condi- 
tion. For  all  classes  of  women  there  was  a  slight  increase  in  the 
length  of  flow  when  it  became  free  from  pain  in  after  life.  Where 
pain  had  existed,  the  change  was  greatest,  as  shown  in  the  reduction 
of  the  length  of  flow  for  the  sterile  women,  while  the  average  remained 
but  little  changed  for  the  fruitful  with  either  condition,  as  to  pain. 
The  increased  duration  for  those  who  had  been  free  from  pain  was 
almost  entirely  confined  to  the  unmarried. 

On  the  total  number  who  were  regular  from  the  first,  no  change 
took  place  in  after  life,  the  average  duration  of  floAv  remaining  the 
same  as  it  was  at  puberty.  But  for  all  women  Avho  were  regular 
yet  suff"ered  from  pain,  the  time  of  flow  was  shortened.  The  only 
apparent  exception  to  the  general  rule  was  with  the  fruitful  women, 
who  had  pain  in  the  beginning  of  the  flow,  and  for  this  class  there  was 
practically  no  change.  Where  the  flow  had  been  free  from  pain,  but 
regular  from  the  beginning,  the  average  for  the  unmarried  and  fruit- 
ful women  was  lengthened,  wdiile  that  for  the  sterile  remained  un- 
changed. 

In  all  women  who  become  regular  after  a  certain  time,  the  men- 
strual flow  was  shortened  in  after  life.  Under  the  same  classification 
the  period  became  lessened  also  with  all  Avomen  who  sufi"ered  from 
pain.  When  free  from  pain  the  average  duration  was  increased  for 
the  unmarried,  and  lessened  for  the  sterile  women,  but  on  the  total 
average  it  became  shortened  for  both  classes.  The  average  for  the 
fruitful  women  remained  unchanged  from  puberty  where  pain  had  ex- 
isted at  the  beginning  of  the  flow,  but  under  each  other  condition  and 
on  the  total  number  it  was  also  lessened  in  duration. 

The  average  for  the  total  number  of  women  who  were  never  reo-ular 
shows  that  the  period  became,  in  the  same  manner,  shortened  during 
after  life.  On  making  a  comparison  between  each  class  of  women,  it 
is  found  that  the  average  was  reduced  for  the  unmarried  and  fruitful 
while  the  floAv  was  lengthened  for  the  sterile.  For  the  total  number 
of  women  who  had  suffored  pain  either  at  the  beginning,  or  during  the 
flow,  or  had  been  free  from  pain,  and  had  never  been  regular,  the 
flow  become  less.  As  was  the  case  with  those  who  had  become  resru- 
lar  afterwards,  but  suffered  pain  at  the  beginning  of  the  period,  the 
unmarried  of  this  class,  who  were  never  regular,  menstruated  for  a 
lono;er  time  in  after  life,  while  the  average  for  the  fruitful  remained 
unchanged.  Under  the  same  conditions,  the  duration  was  shortened 
for  the  sterile  women.     With  pain  during  the  flow,  the  average  was 


170 


OVULATIOX    AXD    MEXSTKU ATIOX , 


5^ 

"Si 


^ 

^ 


•6 


^ 


^ 

e 
s 


i,;r 


I 


3: 

■suouTpuoo  x^e 
10}  jaqranii  I'cio; 
sq?  jooSBinaojoj 

|^55^=-S 

'  ~i'^  '^  ^^'^ 

< 
o 

•gjiX  jajjB  nx 
poiiad  oqi  jo 
xjjSnai  aSxijaAy 

■^  O  cq  ^  -^  Til 

-i' 

-i^  d  ec  o  cc-*      -? 

pouad  ^^%  jo 
xijSnaj  eSBjaAy 

o  ej  « -J  o  o 

s 

cc  o  -c  o  <n  !M      o 

■^  '.D  r^  t-.  rH  O         t- 

■sas'BD  JO 
joqrauu  ib;ox 

c^  c^i  cc  a;  cc  ^1 

.—  CO  O  CO  Oi-t        -^ 
(MOT  O  «  t-T         g 

a 

■< 
s 
s 

OQ 

Where  menstruation  in 

aftor  life  became  changed 

both  in  length  and 

quantity. 

•UOnxpUOO  XJO'EO 

aoj  oE^jnaojOd; 

',    '.    '.i^*B.^ 

CI 

:  :SL?S 

C4 

CO 

•8JU  JOIJ-B 

xn  poxjod  JO 

'.  :  :  ^  t-  ^ 

;    ;    ;  »='  o4  i~ 

:  :  — '  CO  c-1    ci 

.    ;  C-.  o  r-       s 

;    ;  cd  CO  ^      -* 

•X^Joqxid 
^■8  poijad  JO 
xijsuot  aS-BJOAY 

;    ;    ;  r- 1~  -?' 

az 

;    ;  -?  to  ^      '^ 

•sasBo  JO  jaqran^ 

'.    '.    I^tp 

at 

C5 

:    1 1   ; 

.     .  :o  c:  t-t       ^ 

:  ! 

PS     SS- 

•j-BinSajJi 

.'    I    I    t    !  cc 

CO       1    • 
c:       1    • 

I      !      .      .  CC' 

o 

o 

•pas-eaaoxii 

'.    '.    '.f    \    . 

CI 

i  i^^^  i : 

CO 

5! 

-^5        I 

•panassai 

'.     '     '.     '.O:     '• 

oi         '• 

I     t      .  c;     . 

s 

,-'-b 

•iBxngaiJi 

!;;::■= 

-      : 

;  i  i  i- 

CI 

ci 

ClIANQED  IN 

being  Incro 

and  tho  qufi 

either 

•paxiassai 

i  i  ;  :-  i 

S      : 

M  1"  i 

CO 

•pasBaJoui 

.    .    .  5:    .    • 

ci 

:  is  •  : 

j     ;i 

P5 

■< 

s 
s 

o 

02 

■Where  monstrua- 
tion  In  alter  llfo  re- 
maiuod  unchanged 
in  length.         1 

•HOXUPXIOa  XJOBO 

JOJ  83B}iiaojsa; 

rj  o  cr:  d  t^  X 

3     Sg235§ 

•       "^ 
;        to 

•poijad  JO 
xi^Suax  aS'BjaAV 

o  (N  cc  o  t-  r: 
-*  d  ^  ti  -!?  rj 

S 

:  ^^:^_^^s  t 

■sasBO  JO  jaqnnix; 

««— ■  -HO  Cl 

r- C5  03  ^ -i<  i-H 

o 

;      j?l  m  S  t-r-c4       c^           ;    1 

N  Length 

ho  quantity 
3  afterwards 
either 

•ivinSsiii 

.      .      •      .      ■  (T. 

o    j  : 

:  :  :  :?5 

•panassaq; 

:  •  M-  : 

ci        ; 

!    !    1  cc    • 

;        -? 

« 
< 

z 

•posTjajoxii 

Mi::;! 

-f    i  j   ; 

CO     i|     '• 

:  :r=  :  : 

!         00 

o 

;        e4 

:S  ~  tc 

•A1UB3S 

•  i?:  :  :  : 

ci 

;s  ;  i ; 

ci 

Rkmained 

and  quant 

being  from 

begin nin 

•aajj  00 J, 

i^  M  N 

t> 

CO    ■    ■    •    ; 

•{■Bnijox 

c3  i  i  :  :  : 

;       c4 

1TB.— Figures  ro- 
ing  to  duration  or 
'tU    of    menstrua- 
donoto   tho   timo 
ays. 

-^  ■=    •  1  "5 .5 

2 

a 

u  c     :  :  :  :  :  J    . 

^E  •£     :  :  :  :  ■  1  p 

Z~    =-=  -  2  ?  tc 
gS     5ggH?£ 
:^  -     V.  E-  r.  ~  .::  « 

i>  ninuor 

Porcentago  for    ) 
each  condition,  j 

S5 

III! 

•poujEuiuji              |i^              -aiL-oisj 

CHANGES    IN    MENSTRUATION, 


171 


o 


1^ 


ti  .'-;  o  c^;  --o  o-i 

?o  *f  'J*  o  c^  o 

-H  <M  CO  CO  c;  ^ 

c^  »o  CO  eo'  CO  05 

X,                CO  (M 

?D  GC  -M  t^  C-1  O 

-r  «5  ej  ■='  «  u-; 

CTi 

cn  r^  ,-1  tM  r^  — 

;  j »)« eo  e4  id  CO  'I* 

o 

4.66 
6. .58 
2.72 
4.93 
5.27 
4. SO 

CO 

'  oi  t-.  —  -•  t^  cri 
•o  >.-:  C-.  CO  r-  ■.-: 

-r  CO  ^j  ^  -.o'  -* 

as§3s.= 

<r.  •£  CO  o  CO  •- 
j  1  CO  ^  i^  »  >o  '-' 

o 

coeoeo 

c;  o  d 

e; 

"' 

lO  t^  c/: 
Cl  1--  q 

cj 

CO 

CO 

o  «  •': 

3 

■■".  (^i  ^ 
o  eo  •--5 

I^  00  o 

-j!  d  o 

-*  13  -* 

^  ; 

O  CO  CO 

CO  -»<  CO 

CO 
CO 

iS3 

CJCl 

CO 

2 

1^ 

Cl 

ca 

CI 

c 

CI  CO 
■O  CO 

o 

o 

t^ 

» 

1-  'O 

I-;  q 
d  CO 

q 
c-i 

3 

CI 

?, 

^ 

CO  CO 

CO  q 
d  ci 

ci 

CO 
CI 

ci 

■^        ^ 

ci 

-*  d 

2 

CO 

CI 

1       o 

r.-  -H 

o 

C3 
CO 

CO 

E 

CO 

q  t-; 

-i  d 

^  t^  t.-  o  —  o 

.Ot--t-  =-.  ~:  r-; 

IS  1 

CO 

C  O  CO  CO  CI  -*- 

ii  CO  q  — _  — .  I- 
CO  t^  d  cc  t-^  CO 

Cl         1-^  CI  r- 

CO 

CO 

to  CO  c-J  ^?  :=  -.= 
o  o  t>-  -)<  •--:  -^_ 
-*  «d  ci  o  -4<  1" 

~i 

-)^  CO  c4  >o'  ril  -~ 

o  o 

O  C  O  ■?>  «  >f5 

% 

[^S.=;S  CO  Cir-c 

1 

CO 

- 

CI        1 
CO 

t~ 

r- 

5 

Cl  CI 

- 

CO 

'% 

ci 

o 

CO 

■o  o 

(M 

CI     ! 

CO 

q 
d 

CO  CO 
CO  CO 

d  d 

o  : 

CI 

-o 

CO 

s 

CO 
CO 

q  q 
ci  ci 

^o 

- 

CO 

CI 

iO  lO 

d  d 

CO 

CO      ]  |» 

cr. 

CO 

d 

c:c  o 
q  q 

a 

3  ^ 

i 

1 

i 

J  .2  ■  i  : 

- 

1 

: 

c 

o   -^ 

3  "3 
1^ 

^^._>.^^p^ 

^ 

o  3    . 
».  5  " 

lis 

1-  S  o 

o 

3 

s 

«.-  o 

o  r; 

3   2.0 

JO 

t-l 

o 

-"a 
3 

•injjmaj                                               •.fa-Btuwng                                 ' 

172  OVULATIOX    AND    MEXSTRU  ATIOX . 

reduced  for  the  unmarried  and  fruitful  women,  but  increased  for  the 
sterile.  In  this  absence  of  pain,  the  unmarried  menstruated  afterwards 
for  a  much  shorter  time  than  at  puberty,  while  the  flow  was  increased 
greatly  for  the  sterile  and,  to  a  less  degree,  for  the  fruitful  women. 

Menstrual  (Jlianges  in  Qiiantity  and  Duration. — We  have  shown 
in  Table  XII.  yarious  changes  which  took  place  after  puberty  in  the 
menstrual  flow  of  one  thousand  nine  hundred  and  ninety  women.  By 
comparison  with  Table  XI.,  it  will  be  seen  that  a  difference  exists  in  the 
two  tables  between  the  averages  given  of  the  length  of  the  menstrual 
flow  at  puberty  and  in  after  life.  These  are,  however,  so  slight  that 
the  difference  could  easily  have  resulted  from  individual  cases,  and 
are  really  of  little  practical  importance,  since  they  bear  about  the 
same  proportion  to  each  other. 

By  reference  to  the  lower  division  of  Table  XII.  it  will  be  seen  that 
with  1349  women,  or  67.28  per  cent,  of  the  whole  number,  the  length 
of  menstruation  remained  from  puberty  unchanged.  But  of  these  a 
certain  proportion  had  the  quantity  altered.  In  the  first  section  of 
those  with  whom  the  time  remained  the  same,  a  certain  proportion 
were  normal,  too  free,  or  scanty  in  quantity  from  puberty,  and  their 
condition  so  remained.  For  the  second  section  of  the  same  division 
the  qiiantity  became  increased,  lessened,  or  irregular,  but  the  length 
of  flow  continued  also  unchanged.  The  average  duration  of  the 
menstrual  flow  is  given  for  each  condition  as  to  quantity,  and,  in  the 
next  column,  the  percentage  on  the  whole  number  of  cases  belonging 
to  this  class  ;  while  in  the  lower  division  of  the  table  is  shown  the  per- 
centage of  each  on  the  total  number  of  women.  Thus,  with  19.04  per 
cent,  of  all  under  observation,  the  menstrual  flow  remained  normal  as 
to  time  and  quantity,  while  the  number  of  the  same  class  was  28.10  per 
cent,  of  those  with  whom  the  time  remained  unchanged  from  puberty. 
In  this  connection  it  will  be  noted  that  a  larger  proportion  of  the 
unmarried  remained  normal  and  unchanged  as  to  time  and  quantity, 
while  the  smallest  percentage  was  for  the  fruitful  women. 

Of  the  total  number  under  observation,  641  women,  or  32.21  per 
cent.,  suffered  a  change  in  both  time  and  quantity.  In  the  fii*st  section 
of  this  division  the  time  became  lengthened,  with  the  quantity  either 
increased,  lessened,  or  irregular.  In  the  second  section  the  duration 
of  the  flow  became  shortened,  with  the  quantity  lessened,  increased, 
or  irregTilar.  The  average  length  of  menstruation  at  puberty  is  given, 
and  Avith  it  the  duration  in  after  life. 

For  the  purpose  of  explaining  the  table,  we  will  take,  as  an  example, 
the  class  with  whom  the  menstrual  flow  was  increased.     Thus  with 


ANALYSIS    OF    TABLE.  173 

380  women,  or  10.09  per  cent,  of  the  total  number  under  observation, 
the  time  remained  the  same  from  puberty,  but  the  f^uantity  increased, 
while  the  average  duration  of  flow  was  5.38  days;  and  this  group  was 
28.16  per  cent,  of  those  with  whom  the  time  remained  unchann-ed : 
273  cases,  or  13.71  per  cent,  of  the  whole  number,  had  the  time 
lengthened  and  quantity  increased ;  and  below,  in  the  same  column, 
is  shown  the  increase  from  4.07  to  5.71  days ;  17  cases,  .85  per 
cent,  of  the  whole,  had  the  time  shortened  from  5.17  to  3.05  days, 
but  the  quantity  was  increased — thus  making  a  total  of  290  with 
whom  the  time  was  either  lengthened  or  shortened,  but,  Avith  both 
classes,  the  quantity  increased.  The  average  duration  of  flow  at 
puberty  for  these  cases  was  4.13,  and  was  lengthened  to  5.56  days. 
These  290  cases  formed  45.25  per  cent,  of  the  number  with  whom 
the  quantity  was  increased,  while  the  time  was  either  lengthened  or 
shortened.  For  the  total  number,  670  cases,  the  average  duration 
of  the  menstrual  flow  at  puberty  was  lengthened  from  4.84  to  5.02 
days,  and  this  class  formed  33.66  per  cent,  of  the  total  number  of 
women  under  observation. 

It  will  be  seen  that  a  smaller  proportion  of  the  fruitful  women  com- 
menced their  menstrual  life  with  the  flow  too  free,  than  either  of  the 
sterile  or  the  unmarried.  But  the  percentage  of  fruitful  with  whom 
the  flow  increased  in  after  life,  is  nearly  twice  as  great  as  the  propor- 
tion for  either  the  sterile  or  unmarried  under  the  same  circumstances. 
On  the  other  hand,  the  proportion  is  greatest  for  the  sterile,  and 
least  for  the  fruitful  women,  Avhen  the  flow  became  reduced  in  quantity 
after  puberty.  More  than  twice  as  many  sterile  as  fruitful  women 
had  scanty  menstruation  at  puberty,  and  the  same  proportion  is  found 
to  continue  in  after  life. 

We  have  already  seen  that  of  the  women  who  were  afterwards 
fruitful  a  smaller  proportion  at  puberty  were  irregular  as  to  time  than 
either  of  the  sterile  or  unmarried.  But  as  regards  irregularity  in 
quantity,  this  table  shows  the  proportion  to  be  greater  for  the  fruitful 
women,  who  were  not  only  irregular  in  this  respect  at  puberty,  but 
continued  so  during  after  life,  showing  that  while  irregularity  as  to 
time  is  often  associated  with  sterility,  this  condition  as  to  quantity  is 
not  a  bar  to  fruitfulness. 

There  are  other  points  in  detail  which  would  be  of  interest  to  the 
student  as  part  of  the  history  of  menstruation^  but  they  are  of  too 
little  practical  importance  to  the  general  reader  to  engage  our  atten- 
tion at  greater  leno;th. 


174        ABNORMAL    CHANGES    IN    THE    MENSTRUAL    FLOW. 


CHAPTER   X. 

ABNORMAL  CHANGES  IN  THE  MENSTRUAL  FLOW. 

Deviations  from  the  normal  standard — Amenorrhoea — Scanty  menstruation — Men- 
orrhagia— Membranous  dysmenorrhoea — Vicarious  memstruation — Hysteria. 

These  changes  are  to  be  regarded  as  symptoms  only,  having  their 
origin  often  in  opposite  conditions,  and  requiring  discrimination  for 
their  proper  treatment.  They  are  only  grouped  together  for  the  con- 
sideration of  common  features,  and  that  repetition  may  be  avoided 
hereafter  when  treating  of  them  separately. 

Deviations  from  a  normal  standard  may  be  classified  under  the 
following  general  heads  : — 

C  in  time,  as  to  regularity  and  duration  of  flow. 
Changes    <  in  quantity/,  from   absence  of  menstruation  to  uterine 
(^      hemorrhage. 

These  changes  are  frequently  accompanied  by  certain 
C  Painful  menstruation, 
Nervous  manifestations,  <  Hysteria, 

\  Functional  reflex  disturbances. 

All  changes  in  time  and  quantity  are  so  closely  allied  that  the 
general  consideration  of  one  class  must  include  the  other. 

We  have  fully  considered  elsewhere  the  absence  of  menstruation, 
due  to  retention,  but  in  the  condition  now  to  be  treated  of,  and  termed 
amenorrhoea,  there  exists  no  obstruction  to  the  escape  of  the  menstrual 
flow.  Amenorrhoea,  a  condition  of  the  non-pregnant  state,  may  be 
defined  as  a  temporary  suspension  of  the  menstrual  discharge  after 
the  organs  of  generation  have  reached  a  somewhat  mature  stage  of 
development. 

The  opposite  condition,  i.  e.,  an  excess  as  to  quantity  and  duration, 
without  reference  to  regularity,  may  be  termed  monorrhagia,  to 
designate  excessive  menstruation,  or,  as  a  general  term,  metrorrhagia, 
or  uterine  hemorrhage.  In  practice  every  gradation  in  quantity  will 
be  found — from  absence  of,  to  excessive  flow. 


A.MENOllRIKEA.  175 

In  the  condition  ^Yhere  amcnorrhoca  exists,  the  organs  of  generation 
are  generally  found  sufficiently  developed,  and  frequently  no  disease 
can  be  detected  to  explain  the  suspension  of  function.  The  cause 
exists  in  some-  defect  in  the  ovary,  but  indirectly  it  is  to  be  traced  to 
some  disturbance  of  the  nervous  system  by  which  the  nutrition  of  the 
whole  body  has  become  impaired.  This  is  the  rule,  but  apparent  ex- 
ceptions are  met  with  where,  Avith  excess  of  general  nutrition,  men- 
struation ceases  or  becomes  scanty,  and  is  attended  with  atrophy  of 
the  ovaries  and  uterus  early  in  life  ;  yet,  after  all,  when  these  organs 
do  undergo  fatty  degeneration,  the  change  is  but  one  of  faulty  nutri- 
tion. 

Amenorrhoea  does  not  always  accompany  an  anaemic  condition,  since 
profuse  menstruation  often  occurs  in  the  early  stages  of  phthisis  and 
other  diseases,  where,  however,  the  rule  is  for  nature  to  suspend  the 
flow,  as  if  to  husband  the  strength  by  putting  a  stop  to  all  extra  waste. 

Atrophy  of  the  uterus  is  often  found  in  connection  with  amenor- 
rhoea, not  as  the  cause,  but  as  an  effect  of  a  common  cause,  since  I 
have  frequently  observed  atrophy  taking  place  after  the  amenorrhoea 
had  existed  for  some  time. 

It  may  be  questioned  if  amenorrhoea  can  take  place  in  health. 
When  a  sudden  suppression  of  the  menstrual  flow  occurs  from  emotional 
causes,  or  from  exposure,  the  result  should  be  accepted  as  evidence 
of  some  previous  defect  in  the  nervous  system,  although  the  female 
may  have  been  at  the  time  apparently  in  good  health. 

I  have  known  an  instance  in  which  menstruation  was  suddenly 
arrested  at  the  age  of  thirty  by  the  announcement  of  the  death  of 
the  husband,  although  the  wife  had  been  apparently  in  good  health  ; 
but  her  nervous  system  had  been  over-taxed  by  anxiety  for  her  hus- 
band's condition,  and  the  result  Avas  that  she  never  menstruated 
again,  and  atrophy  of  the  uterus  took  place  soon  after. 

I  have  met  with  a  similar  effect,  and  equally  early  in  life,  caused 
by  a  favorable  verdict  in  a  suit  Avhich  had  been  the  source  of  much 
anxiety,  and  upon  the  result  of  Avhich  depended  a  condition  of  afiluence 
or  poverty. 

Another  instance  I  have  known  in  which  a  young  woman  who  had 
been  previously  in  perfect  health,  over-taxed  her  nervous  system  and 
nutrition  to  gain  the  highest  honors  at  one  of  the  female  colleges. 
During  the  time  of  her  course  she  had  menstruated  regularly,  although 
often  too  freely,  yet,  from  the  time  she  gained  the  prize  she  ceased  to 
menstruate,  although  several  years  had  elapsed,  and  atrophy  had  taken 
place  when  I  first  saAY  her. 


176         ABNORMAL    CHANGES    IN    THE    MENSTRUAL    FL0T7. 

The  young  woman  who,  on  getting  her  feet  wet,  has  the  menstrual 
flow  arrested,  with  atrophy  of  the  uterus  sometimes  following,  suffers 
in  the  same  way,  although  there  may  seem  to  he  but  little,  if  any, 
similarity  in  causation — exposure  in  the  one  case,  and  emotional  in- 
fluence in  the  other.  Every  girl  who  gets  her  feet  wet  during  the 
menstrual  period  does  not  necessarily  suff'er  ill  consequences,  nor  does 
every  woman  have  suppression  who  has  been  exposed  to  a  sudden 
nervous  impression.  There  must  have  been  a  previous  depression  of 
innervation,  leaving  a  local  condition  too  feeble  to  react  from  such  a 
shock,  which,  like  the  thunderbolt,  has  its  whole  force  expended  on 
some  ganglion  or  nerve  centre,  the  effect  of  which  would  be  a  paralysis 
or  suspension  of  the  needed  impulse  from  the  neiwe  centre  to  the 
organ  under  its  special  influence.  Each  ganglion,  it  is  thought,  has 
the  power  of  generating  within  itself  a  certain  amount  of  nerve  force, 
which  it  holds  in  reserve  to  resist  any  sudden  shock.  This  vital  force 
is  life,  and  while  a  portion  is  concentrated  in  the  nerve  centres,  the 
rest  is  sent  out  to  the  organ  or  organs  within  its  jurisdiction,  as  it 
were,  and  this  stimulus  is  health.  When  this  influence  fails  to  reach 
an  organ,  nutiition  at  once  suff'ers,.  and  atrophy  naturally  follows. 
^\e  have  already  noted  the  relation  between  the  sympathetic  system 
and  nutrition,  and  their  connection  with  the  circulation.  If  we  accept 
these  views  there  can  be  no  other  explanation  than  that  the  failure 
begins  at  some  nerve  centre,  by  which  its  influence  is  lost,  so  that 
functional  disturbance  is  the  consequence.  When  this  nervous  stimulus 
has  been  suspended  sufficiently  long  to  bring  about  atrophy  of  the 
uterus,  we  may  naturally  infer  that  the  ovaries  had  j)re^iously 
sufi"ered. 

If  this  be  the  correct  relation,  it  must  necessarily  narrow  our  field 
of  treatment  to  improving,  as  far  as  possible,  the  general  condition, 
and  but  little,  if  any,  favorable  results  can  be  expected  from  local 
means.  I  have  seen  a  temporary  increase  in  the  size  of  the  uterus 
in  consequence  of  the  congestion  attending  the  use  of  sponge  tents  or 
from  electricity  locally  applied.  But  there  can  be  no  restoration  of 
function,  unless  the  general  defect  can  be  remedied.  To  accomplish 
this,  we  must  resort,  if  possible,  to  the  means  enumerated  in  the 
chapter  under  the  head, of  general  ti'eatment,  making  such  changes 
or  additions  as  the  peculiarities  of  each  case  may  suggest. 

Scanty  menstruation  may  be  regai'ded  as  but  a  difference  in  degree 
from  amenorrhoea.  As  a  rule,  the  same  general  causes,  as  regards 
impaired  nutrition,  will  lessen  the  amount  of  flow.     There  are  ex- 


IRREGULAR    MENSTRUATION.  177 

ceptions,  however,  and  yet,  not  strictly  so,  since  a  local  congestion, 
or  a  condition  by  which  the  circulation  is  obstructed,  will  produce 
the  same  result.  We  have  seen  such  a  degree  of  obstruction  to  the 
circulation  in  the  uterus,  from  congestion,  that  the  menstruation  be- 
came scanty  or  absent.  This  result  is  common  also  in  cases  of 
inflammation  of  the  mucous  membrane  in  any  other  portion  of  the 
body,  the  congestion  being  so  great  as  to  be,  as  it  were,  above  the 
secreting  point. 

The  condition  of  amenorrhoea,  as  well  as  that  of  a  scanty  flow,  is 
often  preceded  for  a  period  by  profuse  and  irregular  menstruation. 
The  menstrual  flow  will  frequently  be  very  free  after  the  recent 
occurrence  of  a  backward  version,  but  as  the  congestion  increases, 
and  a  permanent  retroflexion  results,  it  will  become  both  scanty  and 
irregular.  The  same  result  is  the  rule  Avith  a  flexure  of  the  body 
above  the  vaginal  junction.  With  cellulitis,  the  menstrual  flow  is 
almost  always  very  free  at  first,  but  it  becomes  scanty  afterwards, 
from  obstruction  to  the  circulation,  as  the  parts  which  have  been 
inflamed  begin  to  contract.  The  growth  of  a  fibroid  may  act  me- 
chanically, so  as  to  almost  cut  ofi"  the  supply  of  blood,  particularly  if 
the  woman  has  previously  suff"ered  from  hemorrhage.  Other  examples 
might  be  cited,  but  without  advantage,  since  the  modes  of  treatment 
would  have  nothing  in  common,  and  must  necessarily  be  considered 
hereafter  in  their  proper  connections. 

The  unmarried  woman  between  puberty  and  thirty-five  years  of 
age  is  sometimes  liable  to  irregularity  and  a  diminution  in  quantity  of 
the  flow,  from  the  fact  that  she  has  not  become  a  mother.  But  before 
she  reaches  the  time  for  a  change  of  life,  the  average  length  of  the 
menstrual  flow  will  be  about  the  same  as  it  was  in  the  beginning, 
provided  she  has  escaped  the  development  of  a  fibrous  growth  in  the 
uterus.  The  sterile  Avoman  will  have  the  average  lessened  in  after 
life,  if  she  does  not  sufier  from  a  fibrous  tumor. 

The  woman  who  has  borne  children  is  liable  to  irregularity,  and  an 
increase  in  both  the  quantity  and  duration  of  the  menstrual  flow, 
with  all  her  symptoms  exaggerated,  as  she  approaches  the  time  for 
a  change  of  life.  The  woman  Avho  has  miscarried  is  more  likely  to 
become  irregular  and  profuse  with  the  period  than  if  she  had  carried 
'a  child  to  full  term.  After  a  criminal  abortion,  as  a  consequence  of 
the  cellulitis  which  occurs  in  every  case  almost  without  exception,  the 
flow  is  usually  scanty  and  irregular,  although  at  first  it  may  have  been 
very  profuse. 
12 


178         ABNORMAL    CHANGES    IN    THE    MENSTRUAL    FLOW. 

Menorrhagia. — The  condition  of  amenorrhoea  is  considered,  as  a 
rule,  to  be  associated  with  an  enfeebled  or  scanty  circulation;  monor- 
rhagia, on  the  contrary,  is  always  dependent  on  a  local  congestion, 
or  on  an  obstruction  to  the  circulation  elsewhere. 

The  causes  of  monorrhagia  may  be  generally  classified  as  follows: — 

Constitutional  defects  associated  with  ansemia. 
Obstruction  to  the  circulation,  in  consequence  of  disease  else- 
where. 
Local  causes,  confined  to  the  uterus. 

The  constitutional  condition  rendering  the  woman  liable  to  uterine 
hemorrhage  is  such  as  attends  prolonged  lactation,  malaria,  or  any 
other  disease  by  Avhich  the  blood  is  impoverished.  Disease  of  the 
heart,  liver,  or  kidneys  Avill,  by  obstructing  the  circulation  in  these 
oro-ans,  cause  uterine  hemorrhage.  Chronic  constipation  will  act 
mechanically  by  obstructing  the  return  flow  of  venous  blood  from 
the  pelvis  into  the  portal  system.  Displacements,  cellulitis,  and 
growths  in  the  pelvis,  having  no  direct  connection  with  the  uterus, 
will  also  act  mechanically  by  obstructing  the  circulation,  so  as  to 
produce  uterine  hemorrhage.  New  growths,  as  a  local  cause,  and 
connected  directly  with  the  uterus,  we  will  find,  however,  to  be  the 
most  frequent  cause  of  monorrhagia. 

As  a  rule,  monorrhagia  from  constitutional  causes  is  most  commonly 
found  in  young  women,  while  those  who  have  borne  children,  and  all 
who  approach  middle  life,  suffer  generally  from  a  local  cause. 

The  development  of  fibrous  growths  in  connection  with  the  uterus 
is,  as  stated  before,  the  most  common  cause  of  irregularity  and  increase 
of  the  menstrual  flow,  for  all  classes  of  women.  But  women  who  have 
borne  children  suffer  from  the  effects  of  various  local  injuries,  Avhich 
afterwards  play  a  most  important  part  in  disturbing  menstruation  and 
causino-  hemorrhage.  Laceration  of  the  cervix  will  be  found  to  be  the 
most  fi-equent  injury,  as  well  as  the  most  common  cause  of  irregvilarity, 
both  as  to  time  and  quantity.  Displacements  of  the  organ,  growths 
within  the  uterine  canal,  as  fibrous  polypi,  growths  from  the  mucous 
membrane,  as  granulations,  mucous  polypi,  and  malignant  disease — ■ 
all  cause  uterine  hemorrhage.  When  a  loss  of  blood  continues 
after  a  miscarriage  or  childbirth,  and  the  uterus  has  become  suffi- 
ciently contracted  to  prevent  post-partum  hemorrhage  proper,  the  flow 
may  be  considered  as  due  to  a  portion  of  the  placenta  being  retained, 
or  to  a  lacerated  cervix.  With  the  first  condition,  the  external  hemor- 
rhage is  not  continuous,  but  becomes  more  marked  when  the  uterus 


MENORRHAGIA.  179 

expels  the  clot.  It  is  not  Avithin  my  purview  to  enter  at  any  greater 
length  into  a  consideration  of  hemorrhage  from  this  cause.  Should 
the  bleeding  from  the  vagina  be  continuous,  and  if  there  has  been  any 
laceration  externally,  the  probabilities  are  greater  that  the  cervix  has 
been  deeply  lacerated  so  as  to  involve  the  circular  artery.  I  am  not 
aware  that  any  case  has  been  placed  on  record  where  death  has  re- 
sulted directly  from  this  injury,  but  it  has  entailed  years  of  suffering 
which,  I  am  satisfied,  in  many  instances,  might  have  been  prevented. 
When  this  hemorrhage  occurs,  it  will  add  but  little  to  the  danger  of 
the  patient  to  have  her  well  Avrapped  up  and  lifted  upon  a  proper  table 
for  examination  immediately.  If,  on  introducing  the  speculum,  the 
bleeding  is  found  to  come  from  the  bottom  of  a  laceration  in  the  cervix, 
I  believe  that  it  would  be  good  practice  to  close  it.  This  can  be  done 
by  the  introduction  of  several  interrupted  silver  sutures,  and  the  parts 
may  be  brought  together  in  less  than  ten  minutes,  if  the  operator  has 
the  slightest  dexterity,  for  the  surfaces  are  then  soft,  and  already  lie  in 
contact.  We  will  thus  save  the  patient's  strength,  by  arresting  an 
oozing  which  may  go  on  for  days,  and  we  will  lessen  the  risk  of  blood- 
poisoning  to  which  she  will  be  exposed  as  long  as  these  raw  surfaces 
are  bathed  in  the  uterine  discharges.  We  will  certainly  remove  a 
source  of  irritation,  for  if  the  laceration  be  left  uncared  for,  involution 
will  be  at  once  arrested,  and  if  the  uterus  be  allowed  to  remain  too 
large  the  woman  must  necessarily  suffer  from  a  displacement  or  sagging 
of  the  organ.  As  a  consequence  of  this  injury,  menstruation  will 
suffer  much  derangement,  and  the  patient  must  eventually  submit  to 
an  operation  far  more  serious  in  character  than  it  would  have  been  at 
first. 

There  are  certain  rules  which  are  applicable  to  the  treatment  of  all 
forms  of  hemorrhage  from  the  female  organs  of  generation  not  de- 
pendent on  the  puerperal  state.  Rest  in  the  horizontal  position,  a 
quiet  mind,  a  hard  bed,  and  a  cool  atmosphere  are  essential  for  arrest- 
ing hemorrhage,  without  reference  to  its  cause  or  the  necessary  local 
treatment. 

Internal  remedies  can  be  but  little  relied  upon  to  control  hemor- 
rhage without  the  aid  of  local  means.  Opium,  however,  in  some  form, 
and  by  enemata  or  rectal  suppositories,  should  always  be  employed 
when  necessary  to  quiet  the  circulation,  or  to  allay  pain.  The  com- 
bination of  a  small  quantity  of  ipecac  with  opium,  as  in  Dover's 
powder,  may  take  the  place  of  the  opium  by  the  bowel  when  the  skin 
is  found  dry  and  inactive.     In  the  absence  of  pain  or  nervousness 


180         ABNORMAL    CHANGES    IN    THE    MENSTRUAL    FLOW. 

aconite  may  be  used  with  stimulants  to  quiet  the  heart's  action  when 
the  patient  has  suffered  from  loss  of  blood  ;  but  nutritious  agents,  as 
beef-tea,  must  be  freely  employed  at  the  same  time.  The  acetate  of 
lead  and  opium,  alum,  ergot,  and  other  remedies,  have  also  been  used 
internally.  The  opium  is  as  efficacious  without  the  lead  ;  from  alum 
I  have  never  seen  any  effect  when  taken  internally,  except  nausea  ; 
while  ergot  can  have  little  effect  on  the  bloodvessels  by  exciting  the 
uterus  to  contraction,  unless  the  organ  be  enlarged.  From  five  to  ten 
grains  of  gallic  acid  dissolved  in  equal  parts  of  pure  water  and  cinna- 
mon water,  with  a  little  syrup,  may  be  given  every  two  or  three  hours, 
according  to  circumstances.  Cinnamon  frequently  seems  to  exert  a 
marked  influence  on  the  circulation  of  the  uterus,  and  makes  a  good 
combination  Avith  the  gallic  acid.  Only  from  this  preparation  and 
from  opium  have  I  seen  any  certainty  of  action,  and  even  these  are 
of  but  little  value,  except  to  control  passive  hemorrhage  when  accom- 
panied by  an  anaemic  condition. 

As  soon  as  there  exists  an  indication  of  excessive  flow  an  examina- 
tion must  be  made  with  the  view  of  ascertaining  the  cause,  and  of 
arresting  it  as  soon  as  possible,  that  the  strength  of  the  patient  may 
not  be  dissipated.  When  the  hemorrhage  is  found  to  come  from  the 
uterine  canal,  it  is  best  to  resort  to  a  tampon  at  once,  to  be  introduced 
in  the  manner  already  described  in  a  previous  chapter.  After  the 
bleeding  has  once  been  checked,  a  diagnosis  can  be  formed,  by  di- 
lating the  canal  if  necessary,  and  the  mode  of  treatment  hereafter  to 
be  described  under  the  head  of  the  special  disease  can  be  instituted. 
Should  the  loss  of  blood  be  due  to  the  presence  of  some  malignant 
disease  on  the  cervix  or  in  the  vagina,  a  tampon  would  be  of  little 
service,  and  might  produce  much  irritation.  In  such  cases  I  employ 
large  injections  of  water  as  hot  as  can  be  borne,  and  I  find  that  this 
will  generally  arrest  the  bleeding.  Afterwards,  a  pledget  of  cotton 
soaked  in  a  saturated  solution  of  alum  may  be  carefully  spread  over 
the  surface,  to  be  removed  within  twelve  hours,  by  means  of  a  string 
which  is  left  attached  to  it.  I  no  longer  employ  the  persulphate  of 
iron  as  a  local  agent ;  under  these  circumstances,  if  the  iron  is  used, 
the  vagina  becomes  so  dry  and  irritated,  that^  the  tampon  cannot  be 
again  properly  replaced.  When  a  tampon  is  required,  it  is  best  to 
place  first  a  portion  of  cotton  saturated  with  alum  over  the  cervix,  and 
then  to  fill  the  vagina  with  oakum. 

When,  from  excessive  sexual  intercourse,  from  taking  cold  after  over- 
exertion, or  from  want  of  strength,  a  passive  flow  occurs,  and  out  of 


DYSMENORRHCEA.  181 

time,  or  when  menstruation  becomes  prolonged  beyond  its  usual  length, 
an  injection  of  hot  water,  in  connection  with  the  use  of  gallic  acid,  will 
generally  arrest  the  flow.  When  this  treatment  is  adopted  to  check 
the  flow,  it  is  not  attended  with  the  slightest  danger  to  the  patient, 
since  no  shock  is  communicated  by  it  to  the  nerve  centres.  The  loss 
of  blood  is  arrested  by  a  natural  process,  since  the  stimulus  of  the  hot 
water  causes  the  vessels  to  lessen  their  calibre  by  contraction,  and 
consequently  all  tendency  to  congestion  will  be  thwarted.  Should 
the  flow  result  from  some  obstruction  in  the  pelvis  external  to  the  uterus, 
as  after  an  attack  of  cellulitis,  a  tampon  cannot  be  employed.  The 
chief  treatment  in  this  case  Avill  consist  in  the  use  of  hot  water  injec- 
tions, opium,  and  rest  in  the  horizontal  position,  with  the  hips  elevated. 
Sometimes  a  show  will  depend  upon  a  fecal  accumulation  in  the  colon, 
and  will  continue  from  day  to  day  in  a  quantity  just  sufficient  to  be 
an  annoyance.  Inspissated  ox- gall,  dissolved  in  warm  Avater,  for  a 
large  injection,  to  be  given  while  the  patient  is  on  the  knees  and  chest, 
will  thoroughly  remove  the  obstruction.  We  occasionally  see  in  prac- 
tice young  girls  who  menstruate  very  profusely,  and  no  cause  can  be 
detected  beyond  a  condition  of  general  plethora.  The  treatment  be- 
tAveen  the  menstrual  periods  must  consist  in  regulating  the  diet,  direct- 
ing more  exercise,  the  Turkish  bath,  and  the  free  use  of  saline  purgatives. 
Very  much  the  same  mode  of  treatment  is  useful  for  women  o-oino; 
through  a  change  of  life  who  are  over-plethoric,  and  when  the  hemor- 
rhagic tendency  is  not  due  to  any  recognized  local  condition.  Three 
cases  are  also  benefited  by  a  brisk  mercurial  purgative,  taken  a  few 
days  before  each  period,  but  long  enough  beforehand  that  its  action 
may  not  have  the  effect  of  suppressing  the  flow. 

It  is  of  great  importance  that  a  woman  should  keep  quiet  at  each 
menstrual  period,  long  after  the  supposed  cause  of  hemorrhage  may 
have  been  removed,  that  the  hemorrhagic  habit  may  thus  be  overcome. 

DysmenorrJioea. — Every  woman  even  in  health  will  experience  at 
least  some  degree  of  discomfort  at  the  menstrual  period.  That  she 
should  be  absolutely  free  from  pain  and  suffer  no  inconvenience  at  this 
time  is  an  abnormal  condition.  The  degree  of  pain,  however,  varies 
by  comparison,  not  only  between  individuals,  but  with  the  same  person; 
thus  great  deviations  from  their  usual  habit  will  appear  without  being 
necessarily  due  to  local  disease. 

The  pain  of  menstruation  bears,  as  a  rule,  some  relation  to  the 
amount  of  flow,  being  great  in  proportion  to  the  diminution  in  quan- 
tity, or  to  the  degree  of  obstruction.     This  is  the  rule,  but  menstrua- 


182         ABNORMAL    CHANGES    IN    THE    MENSTRUAL    FLOW. 

tion  frequently  becomes  painfal  when  the  flow  may  have  been  already 
increased  beyond  the  natural  habit,  and  where  no  obstruction  exists 
to  its  free  escape. 

Pain  is  frequently  caused  simply  from  the  increased  flow  of  blood 
to  the  parts,  as  the  current  comes  to  be  turned  in  that  direction  in 
consequence  of  the  hemorrhage. 

But  painful  menstruation,  as  a  rule,  may  be  considered  due  to 
constitutional  causes,  although  sometimes  only  indirectly.  When  a 
woman  is  ansemic,  her  condition  is  favorable  to  neuralgia,  which, 
instead  of  locating  elsewhere,  expresses  itself  in  painful  menstruation, 
when  the  organs  of  generation  happen  to  be  wanting  in  tone.  Were 
it  possible  to  subject  a  woman  in  perfect  health,  and  another  while 
anaemic,  to  exactly  the  same  circumstances  provocative  of  pain,  it 
would  be  found  that  the  latter,  with  her  nervous  system  deranged, 
would  sufier  far  more  than  the  former. 

The  most  common  cause  of  painful  menstruation  has  been  thought 
to  be  the  existence  of  some  mechanical  obstruction  to  the  free  escape 
of  blood  from  the  uterine  canal.  Flexures  of  the  uterus,  where  the 
organ  has  become  bent  on  itself  so  as  to  obstruct  the  canal,  and 
growths  within  the  uterine  tissue,  which  would  act  mechanically  in 
the  same  manner,  may  be  cited  as  examples.  This  view  might  be 
accepted  without  question,  were  it  not  that  every  observer  has  noticed 
instances  where  painful  menstruation  was  not  always  an  attendant  on 
all  forms  of  flexure  or  apparent  obstruction  to  the  canal.  When  a 
flexure  is  formed  above  the  vaginal  junction,  the  condition  is  one 
always  attended  with  pain  during  the  flow,  and  a  state  of  obstruction 
does  exist  beyond  question.  But  with  a  flexure  at  the  vaginal  junc- 
tion, caused  by  the  neck  being  too  long  and  thin  to  remain  straight  in 
the  vagina,  the  angle  at  which  it  is  bent  is  always  more  acute  than 
it  is  with  a  flexure  in  the  uterine  body.  Notwithstanding  this  fact, 
and  although  the  Avoman  will  probably  be  sterile,  she  does  not  neces- 
sarily suffer  from  painful  menstruation.  It  should,  therefore,  be 
noted  that  flexure  of  the  uterine  body  is  a  condition  almost  invariably 
accompanied  by  an  impoverished  state  of  the  general  health.  But 
with  flexure  of  the  cervix  at  or  below  the  vaginal  junction,  the  general 
condition  is  rarely  affected ;  and  if  so,  it  is  not  at  all  in  consequence 
of  an  obstruction  to  the  menstrual  flow,  but  is  due  wholly  to  the  effect 
of  the  sterility  on  the  nervous  system.  It  is  by  no  means  an  un- 
common consequence  of  the  use  of  the  nitrate  of  silver  to  find  the 
womb  nearly  closed,  and  yet  the  condition  seldom  causes  painful 


MEMBRANOUS  DYSMENORRHCEA.  183 

menstruation,  but  always  sterility.  I  have  observed  several  instances 
where  the  mucous  membrane  had  become  so  contracted  over  the  mouth 
of  the  canal,  from  the  use  of  lunar  caustic,  that  the  orifice  was  too 
small  to  admit  the  finest  probe.  In  these  cases,  I  have  seen  the 
menstrual  blood  escape  drop  by  drop  from  the  small  opening.  No 
pain  was  suffered  except  where  the  flow  was  sufficiently  abundant  to 
fill  the  canal  before  it  could  be  emptied.  In  that  case,  pain  was 
caused  by  uterine  contraction,  the  organ  attempting  to  drive  out  a 
clot  which  had  formed  in  consequence  of  the  delay  in  the  escape  of 
the  blood. 

I  feel  satisfied  from  observation  that,  unless  the  flow  is  scanty, 
painful  menstruation  is  accompanied  by  clots,  and  that  their  formation 
does  not  depend  essentially  on  an  obstruction,  I  hold  this  view  from 
the  fact  that  in  several  instances  I  have  seen,  by  the  aid  of  the 
speculum,  one  clot  after  another  expelled  from  the  uterus  with  pain, 
where  the  canal  was  not  only  straight,  but  also  unusually  large. 
Whatever  the  cause  may  be  for  painful  menstruation,  with  flexure  of 
the  uterine  body,  it  almost  always  exists  in  an  aggravated  form,  and 
is  never  relieved  by  a  surgical  procedure  alone.  Occasionally,  Ave  do 
succeed,  after  an  operation,  in  opening  up  the  canal,  where  the  flexm-e 
has  been  in  the  uterine  body,  so  that  an  obstruction  no  longer  exists, 
and  yet,  as  has  been  said,  the  dysmenorrhoea  is  never  relieved  by 
the  operation  alone.  I  can  off'er  no  explanation  for  this  form  of 
painful  menstruation,  except  one  based  upon  theoretical  views ;  yet, 
the  circumstantial  evidence  is  so  conclusive  that  I  believe  further 
observation  will  show  that  my  deductions  have  been  correctly  drawn. 

With  our  present  knowledge  the  Aveight  of  evidence  is  in  support 
of  the  view  already  given,  that  the  Avhole  lining  membrane  above  the 
internal  os  is  removed  at  each  menstrual  period.  In  a  state  of  health 
this  process  of  disintegration,  we  may  assume,  takes  place  with  but 
little  disturbance.  But,  on  the  other  hand,  if,  from  some  abnormal 
condition,  this  process  be  retarded,  nuclei  may  be  furnished  for  the 
formation  of  clots,  Avhich  increase  in  size  until  the  uterus  becomes 
excited  to  contraction  that  they  may  be  expelled.  The  pain  thus 
caused  is  always  intermittent,  a  character  which  goes  to  support  the 
explanation  just  given.  We  thus  have  every  degree  of  suffering, 
from  a  few  pains  at  the  beginning  of  the  flow,  before  relief  is  ob- 
tained, to  the  form  knoAvn  as  membranous  dysmenorrhoea.  In  the 
entire  condition  the  suffering  is  persistent  until,  by  frequent  contrac- 
tions of  the  organ,  the  whole  linino;  membrane  of  the  canal,  above  the 


184         ABNORMAL    CHANGES    IN    THE    MENSTRUAL    FLOW. 

internal  os,  is  thrown  off  in  one  mass.  No  obstruction  exists  in  these 
cases  to  the  free  escape  of  blood ;  at  least,  in  every  instance  which 
has  passed  under  my  observation,  the  uterine  canal  has  been  straight 
and  the  os  sulficiently  open. 

It  has  been  supposed  that  the  formation  of  this  false  membrane,  as 
it  has  been  termed,  is  due  to  ovarian  influence;  but  of  this  we  have 
no  proof  beyond  the  frequent  coincidence  of  pain  over  the  region  of 
one  or  both  of  these  bodies.  The  throwing  off  of  this  coat  from  the 
uterine  canal  is  a  frequent  accompaniment  of  an  enlarged  and  pro- 
lapsed ovary,  but  it  does  not  always  exist  with  this  condition,  and 
sometimes  we  are  unable  to  detect  the  slightest  disease  in  the  ovaries. 

It  has  also  been  supposed  that  this  membrane  was  a  product  of 
inflammation,  but  of  this  we  have  no  proof,  while  the  weight  of  evi- 
dence rather  points  to  the  contrary. 

Mr.  Whitehead^  has  pointed  out  that  the  acid  reaction  of  the  vagi- 
nal secretions  on  the  fibrin,  prevents  the  menstrual  blood  from  coagu- 
lating in  the  vagina,  and  it  undoubtedly  has  this  property.  The  opinion 
of  this  writer,  and  of  others  quoted  by  him,  is  to  the  efiectthat  healthy 
menstrual  blood  is  deficient  in  fibrin.  This  view  was  held  by  Dr. 
Carpenter,  who,  in  his  Physiology,  states  "  when  clots  are  found  in  it, 
therefore,  a  morbid  condition  of  the  secreting  surface  must  be  inferred." 
Mr.  Whitehead  found  the  menstrual  blood  deficient  in  fibrin  after  it 
had  been  exposed  to  the  vaginal  secretions,  but,  when  the  blood  was 
collected  on  its  escape  from  the  uterine  canal,  there  was  but  little  dif- 
ference detected  between  it  and  blood  obtained  elsewhere.  The  ques- 
tion may  be  mooted  as  to  cause  and  effect,  but  the  fact  will  be  recognized 
that,  with  all  these  menstrual  disorders,  the  general  health  is  impaired 
and  the  blood  is  necessarily  deficient  in  properties  which  would  render 
it  less  likely  to  clot. 

We  must  then  accept  the  supposition,  until  proved  to  be  erroneous 
by  further  observation,  that  a  poor  condition  of  the  general  health 
retards  the  disintegration  of  the  uterine  lining  membrane. 

When  the  menstrual  flow  comes  on  at  its  regular  time,  but  before  this 
membrane  is  in  a  condition  to  be  readily  washed  away  as  debris,  a 
nucleus  will  be  furnished  by  it  to  retain  the  blood.  The  blood  will  be 
thus  delayed  in  its  escape  from  the  canal  long  enough  to  form  clot 
after  clot,  which  will  excite  uterine  contraction  with  pain,  until  all  have 
been  expelled. 

•  On  the  Causos  and  Troatnient  of  Abortion  and  Sterility,  by  James  Wliitlicad, 
F.R.C.S. 


DYSMENORRIICEA.  185 

An  undue  amount  of  pelvic  congestion  during  the  menstrual  period, 
either  from  an  increased  fluxion  to  the  parts,  or  from  ohstruction  in  the 
venous  circulation,  may  produce  pain,  at  the  same  time,  in  the  uterus 
and  ovaries,  without  there  being  any  other  direct  connection.  This 
is  a  natural  effect,  since  the  circulation  in  both  is  so  intimately  con- 
nected ;  therefore,  should  local  disease  exist  in  either  ovary,  the  pain 
will  be  well  marked  in  that  neighborhood,  but  merely  as  an  efiect  of 
the  general  pelvic  disturbance.  When  the  ovarian  function  is  defec- 
tive from  some  general  cause,  and  the  ovaries  are  no  longer  able  to 
generate  the  ovarian  influence,  the  uterus  must  necessarily  soon  suffer. 
But  we  have  no  positive  evidence  that  a  diseased  condition  of  one 
ovary  alone  will  necessarily  influence  the  uterine  condition,  while  dis- 
ease of  the  uterus  certainly  does  not  produce  ovarian  disturbance. 

To  recapitulate  : — Whenever  pain  is  expressed  in  the  uterus  and 
ovaries  at  the  same  time,  we  may,  as  a  rule,  conclude  that  both  are 
suffering  from  some  common  disturbance,  and  this  is  generally  to  be 
traced  to  an  obstructed  circulation.  As  this  obstruction  is  increased 
by  the  additional  flow  of  blood  attending  menstruation,  a  coincident 
pain  may  be  produced  in  the  ovary,  due  to  the  aggravation  of  some 
local  disease.  From  the  marked  character  of  the  ovarian  pain,  it  is 
often  assumed  that  any  uterine  disease,  which  may  happen  to  exist  at 
the  time,  is  a  consequence  of  the  ovarian  condition,  while  the  fact  is, 
that  both  are  but  suffering  from  the  effect  of  a  common  cause.  A 
woman  may  suffer  pain  in  the  ovary  at  the  menstrual  period  without 
there  existino;  the  slightest  uterine  disease  which  can  be  detected.  The 
natural  additional  flow  to  the  pelvis  attending  the  period  will  cause 
suffering  when  inflammation  of  the  ovarian  tissue  has  previously  oc- 
curred, or  from  adhesions  binding  the  ovary  down  so  as  to  obstruct 
its  circulation.  The  pain  at  this  time  is  also  often  great,  in  conse- 
quence of  the  presence  of  cicatricial  or  dense  tissue  within  its  own 
structure. 

We  have  no  means  of  recognizing  ovarian  diseases,  unless  the  ovary 
becomes  enlarged,  which  is  comparatively  rare,  and  on  post-mortem 
examination  the  evidences  of  disease  are  very  rare  in  comparison  with 
the  pathological  changes  found  in  the  uterus  itself. 

Therefore,  my  convictions  are,  that  ovarian  disease  has  but  little 
share,  as  compared  with  the  uterus,  in  the  pain  of  menstruation. 

In  the  absence  of  any  proof  as  to  the  connection  between  disease 
of  the  ovary  and  membranous  dysmenorrhoea,  I  am  disposed  to  attri- 
bute the  discharge  of  the  membrane  en  masse  to  a  want  of  general 


186    ABNORMAL  CHANGES  IN  THE  MENSTRUAL  FLOW. 

tone.  If  we  can  accept  the  supposition  that  painful  menstruation  is 
ever  due  to  a  delay  in  the  breaking  down  of  the  lining  membrane 
of  the  uterus,  it  would  be  but  another  step  in  the  same  direction  to 
attribute  this  "false  membrane"  to  the  same  cause.  Healthy  changes 
in  tissue  do  not  take  place  rapidly  where  the  general  condition  is  as 
much  reduced  as  it  uniformly  is  in  all  cases  which  suffer  from  this 
form  of  painful  menstruation.  Therefore,  it  is  not  improbable  that 
the  Avant  of  general  tone  may  be  the  cause  of  delay  in  this  lining 
membrane  undergoing  the  necessary  fatty  degeneration  before  dis- 
integrating. The  increased  thickening  of  the  membrane  may  be  even 
due  to  perverted  nutrition,  as  unhealthy  granulations  of  increased 
size  may  spring  from  a  surface  in  cases  where  the  subject  suffers 
from  this  same  general  condition.  As  the  menstrual  flow  must  come 
from  the  vessels  below  this  thickened  lining  membrane,  it  would 
necessarily  become  detached  in  one  piece,  and  could  only  be  expelled 
from  the  cavity  by  uterine  contraction,  which  would  be  accompanied 
by  severe  expulsive  pains. 

When  the  uterus  or  ovaries  become  heavy  from  undue  congestion, 
or  suffer  from  any  other  source  of  irritation,  the  impression  then  made 
on  the  extremities  of  the  spinal  nerves  is  at  once  transmitted  to  their 
seat  of  origin  along  the  posterior  portion  of  the  spinal  cord.  Over 
the  spine  will  be  experienced  a  reflexion  of  the  pelvic  irritation.  This 
will  vary  in  degree,  from  the  back-breaking  pain  which  accompanies 
scanty  menstruation,  to  the  marked  sensitiveness  on  pressure  at  some 
special  point,  which,  in  connection  with  some  uterine  or  ovarian  dis- 
ease, is  always  more  marked  when  the  general  condition  is  one  of 
anaemia.  Through  the  aid  then  of  the  sympathetic,  as  has  already 
been  described,  the  mode  by  which  the  disorders  of  menstruation  may 
cause  disturbance  elsewhere,  can  easily  be  understood.  These  mani- 
festations are  recognized  by  various  forms  of  backache,  headache, 
irregular  action  of  the  heart,  nausea,  diarrhoea,  increased  action  of 
the  kidneys,  cold  feet,  chilly  sensations  in  varions  parts  of  the  body, 
and  by  different  forms  of  hysteria.  It  would  be  of  little  practical 
value  to  consider  the  subject  of  reflex  irritation  at  great  length,  and 
to  do  justice  to  the  subject  would  occupy  more  space  than  its  relative 
importance  warrants.  In  a  general  manner,  however,  the  subject 
will  again  be  referred  to  under  the  head  of  treatment  for  hysteria. 

Treatment  of  Dyamenorrlioea. — The  first  necessary  step  will  be  to 
determine  the  cause  of  painful  menstruation,  since  the  proper  course 
of  treatment  must  be  directed  by  tliis  knowledge.     As  diftcrcnt  con- 


TREATMENT  OF  DYSMEXORRHCEA .  187 

ditions  will  produce  the  same  symptoms,  as  regards  pain,  a  physical 
examination  is  often  absolutely  necessary.  A  conscientious  man  will 
seek  to  spare  the  feelings  of  a  young  girl  from  going  through  such  an 
ordeal,  but  it  often  becomes  a  difficult  matter,  in  discharging  one's 
duty,  to  decide  when  it  can  be  avoided.  Where  the  flow  is  scanty, 
painful,  and  probably  irregular,  the  examination  may  be  delayed, 
provided  the  difficulty  occurs  in  early  menstrual  life,  and  the  cause 
may  be  reasonably  attributed  to  over-taxing  the  nervous  system  by 
study.  We  may  then  watch  the  effect  of  an  entire  suspension  of 
brain-Avork,  and  carefully  look  to  improving  the  general  condition. 

I  was  latterly  consulted  by  a  lady  of  this  city  in  regard  to  her 
daughter's  condition  ;  she  had  been  menstruating  regularly  for  two 
years.  For  six  months  after  the  first  menstruation  she  had  experi- 
enced little  pain  or  inconvenience,  but  gradually  the  menstrual  flow 
had  become  more  painful,  and  at  the  last  period  she  had  suffered  so 
much  that  it  had  been  accompanied  by  hysterical  convulsions.  I 
learned  that  she  had  been  growing  so  rapidly  that  it  was  difficult  to 
keep  her  skirts  to  the  proper  length.  She  was  tall  for  her  age,  but 
at  first  glance  seemed  to  have  been  well  nourished,  and  had  a  bricrht 
color.  On  examining,  however,  the  condition  of  her  heart  I  detected 
a  well-marked  anaemic  murmur.  She  had  been  studying  very  hard 
at  home  for  a  year  with  private  masters.  I  gained  the  key  to  the 
situation  when  I  learned,  that  among  her  other  studies,  she  had  been 
in  the  habit  of  devoting  five  hours  daily  to  her  Latin.  I  felt  that 
there  was  no  necessity  of  seeking  for  a  local  cause  under  the  circum- 
stances. I  insisted  that  all  her  studies  should  be  discontinued ;  her 
general  condition  was  looked  after,  and,  as  the  weather  was  mild,  she 
was  directed  to  spend  the  greater  part  of  each  day  at  the  Central 
Park,  in  the  open  air.  There  was  a  great  improvement  at  the  next 
period,  and  by  the  end  of  four  months  she  reported  herself  perfectly 
well,  as  the  last  period  had  been  passed  without  the  slightest  dis- 
comfort. 

But,  whenever  the  pain  lasts  throughout  the  flow,  or  comes  on  after 
it  has  ceased,  with  either  an  increase  or  diminution  in  quantity,  and 
if  there  is  any  pain  or  fatigue  from  standing  or  walking,  the  exami- 
nation must  be  made.  Under  these  circumstances,  the  physician  will 
not  discharge  his  duty  if  he  neglects  doing  so,  or  does  not  have  it 
made  by  some  one  else  if  he  has  not  himself  had  the  necessary 
experience.  The  investigation  is  particularly  called  for  Avhen  the 
occurrence  or  cause  of  pain  can  be  traced  to  a  fall  or  injury,  or  to  a 


188         ABNORMAL    CHANGES    IN    THE    MENSTRUAL    FLOW. 

checking  of  the  menstrual  flow.  If  neglected,  a  condition,  as  the 
result  of  a  displacement,  or  of  disturbance  in  the  circulation,  will 
become  established  as  a  habit,  which  may  only  terminate  with  the 
life  of.  the  invalid.  There  exists  sometimes  a  form  of  retroversion, 
having  its  beginning  at  puberty,  and  to  be  referred  to  hereafter,  which 
must  be  corrected  at  an  early  age,  or  a  retroflexion  in  after  life  will  be 
the  consequence.  By  the  passage  of  the  index  finger  into  the  rectum 
of  a  young  girl,  a  vaginal  examination  may  sometimes  be  avoided. 
By  this  mode,  we  can  judge  of  a  displacement,  the  occurrence  of  a 
present  or  previous  cellulitis,  and  of  the  condition  of  the  ovaries, 
should  they  be  enlarged.  It  is  of  the  utmost  importance  to  determine 
if  either  of  these  conditions  exists,  in  connection  with  painful  men- 
struation in  a  young  girl,  and  we  should,  therefore,  at  least  make  the 
rectal  examination.  If,  from  this  exploration,  it  should  be  deemed 
necessary  to  make  an  examination  by  the  vagina,  it  is  better  to  give 
ether.  We  will  thus  spare  much  pain,  both  mental  and  physical, 
while  from  the  relaxing  effect  of  the  ether  the  opportunity  will  be 
afforded  for  a  thorough  investigation,  and  also  to  dilate  the  parts 
sufiiciently  for  applying  the  subsequent  treatment  if  any  be  necessary. 

This  subject  might  have  been  treated  of  under  the  head  of  a  "mode 
of  examination."  But,  as  I  wished  to  avoid  repetition,  and  to  im- 
press the  importance  of  gaining  an  accurate  knowledge  of  the  condi- 
tion of  disease  in  young  girls,  I  have,  as  a  digression,  considered  the 
matter  in  connection  with  painful  menstruation.  Dysmenorrhoea,  to 
any  marked  degree,  almost  always  implies  some  important  complica- 
tion which  should  not  be  disregarded  at  any  period  of  life,  but  espe- 
cially is  it  paramount  that  we  should  fully  appreciate  the  exact  condi- 
tion causing  it  in  early  life.  Let  us  bear  in  mind  the  important  fact 
already  pointed  out,  that  of  all  married  women  who  had  suffered  pain 
during  the  menstrual  flow  in  early  life,  71.90  per  cent,  were  sterile 
afterwards.  I  can  scarcely  turn  over  a  dozen  pages  of  one  of  my 
case  books  without  recognizing,  by  the  history  of  some  case,  that  the 
woman  was  indebted  for  her  condition  of  sterility  or  bad  health  to  the 
prudish  incapacity  of  her  medical  attendant  in  early  life.  Nature 
will  accomplish  marvellous  results  sometimes  ii\  restoration,  but  let 
the  physician,  as  a  matter  of  conscience,  be  fii'st  satisfied  as  to  how 
far  he  may  be  justified  in  trusting  to  nature,  and  not  remain  in  abso- 
lute ignorance  of  her  capacity  to  perform  the  task. 

When  a  young  woman  suffers  from  any  local  disease,  it  is  rational 
to  suppose  that  she  should  receive  the  proper  treatment  for  her  rcsto- 


TREATMENT    OF    DYSMENORRII  (EA  .  189 

ration  to  health  as  she  would  if  she  were  older.  A  certain  amount 
of  physical  pain  may  he  unavoidable  without  ether,  Ijut  if  a  youn"- 
girl  suftcrs  the  slightest  injury  to  her  modesty  or  moral  condition  by 
an  examination,  or  the  necessary  treatment  afterwards,  the  detriment 
will  come  from  the  method  and  not  the  occasion. 

DysmenorHuiea  is  rarely  a  consequence  of  any  condition  which  can 
be  corrected  without  subjecting  the  patient  to  a  systematic  course  of 
treatment,  so  that  certain  palliative  means  will  have  to  be  resorted  to, 
from  time  to  time,  until  the  cause  has  been  removed.  For  the  local 
treatment  of  dysmenorrhoca,  as  a  symptom  only,  the  reader  must 
refer  to  the  diiFerent  conditions  causing  it.  These  are  to  be  found 
under  the  head  of  flexures,  uterine  growths,  lacerations  of  the  cervix, 
inflammation  of  the  pelvic  tissues,  and  its  consequences,  displacements 
of  the  uterus,  and  the  various  conditions  of  the  nervous  system  closely 
connected  with  faulty  nutrition. 

We  have  stated  the  rule  that  suppressed  or  a  scanty  menstrual  flow 
is  a  condition  generally  accompanied  by  pain.  When  we  are  called 
upon  to  relieve  a  woman  suffering  with  this  condition  of  the  flow,  it  is 
all-important  that  we  should  have  a  knowledge  as  to  the  cause.  We 
will  exclude  those  acting  mechanically,  as  they  are  to  be  treated  of 
hereafter,  a  faulty  condition  of  the  circulation,  for  example,  being  one 
of  them. 

From  venous  fullness,  the  pelvic  organs  may  be  so  charged  with 
blood  as  to  suspend  the  flow,  or  cause  it  to  be  scanty  and  painful. 
From  arterial  fullness,  the  pelvic  organs  may  be  congested  to  the 
verge  of  inflammation,  and  the  uterus  be  above  the  secreting  point, 
or  furnishing  painful  and  scanty  menstruation.  From  deficient  ovarian 
action  amenorrhoea  or  a  scanty  and  painful  flow  may  be  found,  Avith  or 
without  pelvic  congestion. 

We  will  be  consulted,  at  the  time  of  menstruation,  only  for  the 
relief  of  one  of  these  three  conditions.  Then  the  question  will  arise 
as  to  the  proper  mode  of  increasing  the  flow  in  quantity,  that  it  may 
escape  faster  from  the  canal  without  forming  a  clot  to  excite  the  organ 
to  painful  contraction  for  its  expulsion. 

The  first  condition  cited,  that  of  venous  congestion,  is  but  an  in- 
crease in  degree  of  the  state  described  as  accompanying  all  uterine 
diseases  of  long  standing.  It  is  one  where  the  vessels,  having  already 
lost  their  tone  from  impaired  nutrition,  become  distended,  almost  to  a 
state  of  stagnation,  in  consequence  of  the  increased  flow  of  blood  to  the 
pelvis  at  the  time  of  the  menstrual  period. 


190         ABNORMAL    CHANGES    IN    THE    MENSTRUAL    FLOW. 

The  first  effort  must  be  directed  to  lessening  the  amount  of  blood 
in  the  pelvis,  and  to  distributing  it  to  the  skin  and  extremities.  When 
the  suffering  is  very  great,  "with  a  scanty  flow,  I  often  administer  an 
emetic  of  ipecac,  and  cover  the  woman  up  warm  in  bed.  As  soon  as 
the  stomach  becomes  settled,  the  feet  are  to  be  put  into  a  deep  foot- 
bath of  hot  water  and  mustard.  The  bath  should  be  administered  as 
the  patient  lies  in  bed,  and  with  as  little  exposure  as  possible.  This 
can  be  done  by  placing  something  under  the  tub  so  as  to  elevate  its 
edge  nearly  to  the  same  level  with  the  bed.  Care  must  be  taken  to 
arrange  the  bedclothes  so  that  they  cannot  become  wet,  and,  to  pro- 
tect the  patient's  limbs,  an  extra  blanket  should  be  spread  over 
them  and  the  tub.  An  additional  quantity  of  hot  water  should  be 
added  from  time  to  time,  so  as  to  keep  the  temperature  elevated  to 
as  high  a  point  as  can  be  borne.  It  is  better  that  the  feet  should 
be  retained  in  the  bath  until  the  skin  has  begun  to  act,  when  it  is 
probable  the  first  relief  will  be  experienced  by  the  patient.  That 
the  action  may  not  be  checked,  the  patient  should  lift  her  feet  from 
the  water  as  the  tub  is  withdrawn  from  under  the  blanket,  without 
exposure.  Then  the  limbs  must  be  quickly  wrapped  in  the  blanket 
which  has  covered  them,  and  without  drying  the  feet.  To  increase 
the  action  of  the  skin,  some  hot  drink  should  be  administered. 
Nothing  is  better  than  a  cup  of  tea  made  by  pouring  hot  water  on  a 
little  essence  of  Jamaica  ginger,  to  which  may  be  added  milk  and 
sugar  to  make  it  more  palatable.  The  main  object,  however,  is  the 
hot  drink,  and  any  thing  else  in  the  form  of  a  tea  will  answer.  I 
employ  the  ginger  on  account  of  its  being  a  mild  stimulant,  and  because 
it  answers  well  to  settle  the  stomach  after  the  emetic.  A  stimulant 
is  often  serviceable,  and  this  is  quite  sufficient  for  the  purpose,  even 
if  an  emetic  has  not  been  employed ;  and  it  is  preferable  to  the  gin 
and  water  which  is  generally  used  as  a  household  remedy  under  the 
same  circumstances.  To  keep  up  the  action  of  the  skin  I  usually  ad- 
minister, before  the  effect  of  the  tea  has  passed  away,  half  an  ounce 
of  the  liquor  ammoniee  acetatis  and  a  third  of  a  grain  of  ipecac,  every 
two  or  three  hours.  As  soon  as  the  flow  becomes  well  established, 
this  remedy  can  be  suspended,  but  the  patient  should  i-emain  in  bed 
well  covered  up,  with  a  receptacle  for  hot  water  at  her  feet. 

When  the  pain  is  not  severe  the  emetic  may  be  dispensed  with,  and 
the  hot  foot-bath  will  be  sufficient  if  the  action  of  the  skin  is  kept  up 
afterwards.  Great  relief  will  be  given  sometimes  to  the  backache  by 
lifting  up  the  uterus  on  the  index  finger  for  a  short  distance  in  the 


TREATMENT    OF    DYSMENORRIICEA .  191 

pelvis,  and  holding  it  in  this  position  for  a  -while.  As  has  been  pre- 
viously shown,  this  manoeuvre  allows  the  uterus  to  relieve  itself  of  the 
congestion  produced  by  the  prolapse,  and  by  the  traction  on  the 
vessels  in  the  connective  tissue  of  the  pelvis.  If,  at  length,  sufficient 
relief  has  not  been  obtained,  an  anodyne  must  be  administered,  and 
it  will  be  more  efficacious  by  the  rectum,  I  generally  use  a  supposi- 
tory of  morphine  and  belladonna,  but  we  should  avoid  anodynes  if 
possible,  since  after  their  use  the  flow  is  not  likely  to  be  as  free,  and 
the  action  of  the  skin  will  be  lessened.  AVhen  opium  in  any  form  has 
been  used,  it  is  best  to  establish  a  revulsive  effect  along  the  spine, 
since,  as  I  have  often  observed,  the  kidneys  are  then  more  likely 
to  increase  their  action,  and  there  will  be  less  suffeiing  from  the 
after  effects  of  the  remedy.  This  can  be  done  by  placing  a  mustard 
plaster,  about  three  inches  in  width,  from  the  cervical  region  to  the 
sacrum.  A  rapid  action  is  needed,  and  to  produce  this,  the  una- 
dulterated mustard  flour  must  be  rubbed  up  into  a  thick  paste  with 
warm  water,  and  then  reduced  to  a  proper  consistency  by  adding  an 
ounce  or  two  of  syrup  or  molasses,  which  will  at  once  develop  the 
volatile  oil.  A  piece  of  unstarched  muslin  of  the  proper  length,  and 
of  some  nine  inches  in  width,  is  used.  The  cloth  is  to  be  laid  out 
at  full  length,  and  the  mustard  spread  down  the  centre  for  one-third 
of  the  width,  so  that  when  it  is  folded  over,  the  mustard  Avill  be 
covered  on  one  side  by  two  thicknesses  of  the  cloth.  As  the  patient 
will  be  suffering  more  or  less  from  some  nervous  disturbance,  an 
hysterical  convulsion  may  be  brought  on  by  the  shock  if  the  mustard 
is  applied  cold.  The  surface  covered  by  the  single  thickness  of  cloth 
must,  therefore,  be  warmed  by  holding  it  in  front  of  a  fire,  or  in  any 
other  manner,  and  kept  folded  together  until  it  is  applied.  The  skin 
will  become  red  in  from  ten  to  twenty  minutes,  and  th^  plaster  should 
not  be  allowed  to  remain  longer,  even  if  the  patient  should  not  com- 
plain of  the  pain  produced  by  it.  It  would  be  better  to  reapply  it  in 
an  hour  or  two  than  to  blister  the  surface,  which  would  cause  un- 
necessary suffering  afterwards.  If  the  flow  has  come  on,  and  the 
object  is  to  relieve  the  backache,  and  to  quiet  nervousness,  a  little 
mustard  can  be  mixed  with  ground  flaxseed  into  a  poultice,  so  that  it 
may  remain  with  safety  for  a  longer  time.  To  aid  in  bringing  on  the 
flow,  I  have  thought  dry  cupping  to  be  sometimes  more  efficacious, 
provided  the  cups  can  be  applied  early  enough.  They  are  to  be 
placed  on  each  side  of  the  spinal  processes,  and  confined  to  the  im- 
mediate neighborhood  of  any  point  which  may  be  found  unusually 
tender  on  pressure.     I  prefer  to  use  four  or  six  large  tumblers,  since 


192         ABXOEMAL    CHANGES    IX    THE    MENSTRUAL    FLOW. 

the  relief  is  more  prompt  than  Avoukl  be  the  case  were  the  same  space 
covered  with  the  ordinarv-sized  cupping-glasses.  Unless  the  tumblers 
are  unusually  heavy  and  thick,  there  will  be  no  difficulty  in  making 
them  hold  on  after  properly  exhausting  the  air  by  igniting  a  little 
alcohol,  or  by  saturating  some  cotton  or  a  piece  of  paper  stuck  to  the 
bottom  of  the  glass.  As  I  am  not  writing  for  the  benefit  of  experts 
alone,  the  frequent  reference  thus  to  details,  which  may  seem  to  be 
trivial  in  character,  must  be  overlooked  by  those  who  may  not  need 
them.  Therefore,  I  will  add  that  the  cotmter-irritation  should  not  be 
unnecessarily  increased  by  burning  the  patient,  from  either  letting 
the  ignited  cotton  fall  upon  the  skin  before  the  tumbler  reaches  it,  or 
by  overheating  the  glass  before  it  is  applied.  The  first  can  be 
avoided  by  pressing  the  damp  cotton  firmly  against  the  bottom  of  the 
glass  before  dropping  on  the  alcohol.  The  second  by  wiping  off  with 
a  cloth  any  excess  of  alcohol  which  may  have  run  down  to  the  edge  of 
the  glass,  and  by  applying  the  latter  to  the  surface  immediately  after 
igniting  the  alcohol.  From  fifteen  to  twenty  minutes  is  long  enough 
for  the  cups  to  remain  in  one  place,  after  which  they  may,  with  ad- 
vantage, be  shifted  to  another  position. 

For  this  form  of  painful  raenstruation,  the  same  routine  in  treatment 
may  be  necessary  month  after  month,  until  the  local  disease  has 
yielded  to  treatment.  During  the  interval  between  the  periods,  the 
general  condition  must  be  carefully  looked  after,  the  bowels  regulated, 
and  the  skin  well  protected  by  flannel.  A  Turkish  bath  is  often 
beneficial  in  its  effects  when  taken  within  a  week  before  the  expected 
period. 

From  arterial  congestion,  the  pelvic  vessels  may  be  so  over-distended 
as  to  bring  the  lining  membrane  of  the  uterine  canal,  as  it  were,  above 
the  secreting  point ;  and  there  may  be  an  inflammation  about  the 
uterus,  or  a  condition  very  closely  allied  to  inflammation.  In  the 
condition  just  treated  of,  the  organs  have  long  been  accustomed  to 
this  state  of  engorgement  from  want  of  tone  in  the  vessels,  but,  as 
the  veins  are  chiefly  implicated,  there  exists  but  little  tendency  to 
inflammation. 

"When  called  to  a  woman  who  has  checked  her  menstrual  floAv,  by 
getting  her  feet  wet  or  otherwise,  the  hot  foot-bath  must  be  used  at 
once,  and  some  stimulating  hot  drink  given,  to  bring  on  a  reaction. 
If  not  relieved,  both  in  cessation  of  pain  and  a  restoration  of  the  flow, 
it  is  best  to  apply  a  dozen  leeches  about  the  anus,  and  a  hot  poultice 
of  ground  flaxseed  over  the  abdomen,  and  to  administer  ten  grains  of 
Dover's  powder  with  five  grains  of  quinine,  the  dose  to  be  repeated 


TREATMENT  OF  DYSMENORRHCE  A  .  193 

•when  needed.  With  every  care,  the  time  of  the  period  may  be 
passed  without  our  having  succeeded  in  fully  restoring  the  proper 
condition,  and  it  will  then  be  necessary  to  adopt  some  course  of 
treatment  for  her  relief  before  the  expiration  of  the  month. 

We  Avill  generally  be  called  to  treat  a  woman,  under  these  circum- 
stances, who  has  been  in  good  general  health  previous  to  the  men- 
strual check,  although  I  am  inclined  to  accept  the  check  as  an  evi- 
dence of  defect  somewhere.  Yet,  there  seldom  exists  a  sufficient 
impairment  to  contra-indicate  active  treatment,  and  this  congestive 
disturbance  should  be  broken  up  before  it  becomes  a  habit.  The 
temperature  with  this  condition,  when  taken  in  the  vagina,  is  generally 
about  half  a  degree  higher  than  it  is  in  the  axilla.  Should  no  greater 
difference  exist,  it  is  good  practice  to  apply  a  blister  over  the  lower 
portion  of  the  abdomen,  the  size  of  which  is  to  be  regulated  according 
to  the  urgency  of  the  symptoms.  After  the  blistered  surface  has 
healed,  if  any  tenderness  in  the  vagina  can  be  detected  by  the  aid  of 
the  index  finger,  the  patient  must  be  kept  quiet  in  bed,  with  a  poultice 
over  the  abdomen,  and  the  leeches  again  applied  about  the  anus. 
This  position  is  preferable  to  the  neck  of  the  uterus  for  leeching,  since 
the  pelvic  circulation  can  thereby  be  as  well  influenced,  while  leeches 
cannot  be  applied  in  the  vagina  of  a  young  woman  without  inflicting 
great  pain  and  annoyance,  with  the  risk,  also,  of  inducing  too  great 
a  loss  of  blood.  But  the  chief  object  in  selecting  some  other  position 
than  the  neck  of  the  uterus  is,  to  avoid  adding  any  additional  source 
of  irritation  to  this  organ,  already  over-congested,  since  an  increased 
flow  of  blood  always  takes  place  for  a  time  at  least  to  the  neighbor- 
hood of  leech-bites.  The  hot  water  vaginal  injections  should  be  used 
at  night  and  in  the  morning,  and  iodine  freely  applied  to  the  vagina 
and  posterior  cul-de-sac  every  four  or  five  days.  Should  there  have 
been  no  cellulitis  or  tenderness  about  the  uterus,  a  sponge  tent,  small 
in  diameter,  but  of  the  proper  length,  may  be  introduced  two  days 
before  the  expected  flow.  This  is  to  be  removed  on  the  following  day, 
the  uterus  washed  out  with  a  little  warm  Avater,  and  another  tent 
of  the  same  size  introduced,  to  be  withdrawn  on  the  morning  of  the 
expected  period.  It  is  prudent  that  the  patient  be  kept  in  bed,  and 
all  the  directions  observed  which  have  been  already  given  in  relation 
to  the  use  of  sponge  tents.  The  employment  of  sponge  tents  is,  of 
course,  inadmissible  when  there  is  the  slightest  tendency  to  inflamma- 
tion in  the  pelvic  connective  tissue  or  in  the  ovaries.  Should  this 
condition  exist,  it  must  receive  our  chief  attention,  and  we  should 
enjoin  absolute  rest,  and  prescribe  other  appro j)riate  remedies.  An 
13 


194        ABNORMAL    CHANGES    IN    THE    MENSTRUAL    FLOW. 

important  measure  is  the  judicious  use  of  opium.  We  will  be  obliged 
to  wait  for  improvement  in  the  menstrual  disorder  until  the  more 
urgent  complication  has  been  removed. 

The  third  condition  is  to  be  found  when  there  has  been  an  arrest  of 
development,  or,  for  some  time,  imperfect  ovulation.  If  there  has  not 
been  a  sufficient  cause  to  determine  an  arrest  of  development,  amenor- 
rhoea  or  a  scanty  flow  will  be  established  without  any  material  change 
for  a  time  in  the  size  of  the  uterus.  The  menstrual  flow  becomes  less 
or  ceases,  but  not  in  consequence  of  failure  in  the  ovaries  to  mature 
an  ovum  at  the  time  of  that  special  menstrual  period.  A  change 
takes  place  gradually,  ovulation  having  been  imperfectly  performed 
for  some  time  previous,  and  without  the  proper  amount  of  stimulus  to 
emit  the  needed  ovarian  influence.  Until  atrophy  of  the  organs  of 
generation  have  been  produced,  a  periodical  floAv  of  blood  to  the  pelvis 
will  continue  to  take  place,  in  a  greater  or  less  degree,  as  a  result  of 
habit.  Consequently,  the  woman  will  sufier  with  intense  back-ache 
from  the  increased  weight  of  the  uterus,  and  from  ovarian  pain,  also 
a  result  of  the  congestion. 

This  result  is  often  but  an  evidence  of  an  advanced  stage  of  the 
second  condition  described,  and  the  length  of  arterial  congestion,  or 
inflammatory  period,  varies  much  in  different  cases.  At  a  later  period, 
as  the  general  health  becomes  impaired,  but  before  atrophy  of  the  uterus 
has  come  on,  the  pelvic  veins  lose  their  tone,  and  the  local  condition 
approximates  closely  to  the  one  described  as  attending  all  uterine  dis- 
ease of  long  standing.  As  an  attendant  on  scanty  and  painful  men- 
struation, due  to  imperfect  ovulation,  the  nervous  manifestations  are 
all  more  marked  by  some  form  of  hysteria  than  in  the  first  condition 
where  the  ovaries  perform  their  function,  or  in  the  second  form  which 
is  due  to  arterial  congestion. 

So  long  as  the  uterus  remains  of  normal  size,  there  will  be  a  rea- 
sonable prospect  for  final  restoration,  by  which  the  flow  may  become 
fully  established  in  quantity,  and  the  pain  relieved.  My  chief  reli- 
ance for  the  relief  of  this  condition  has  been  upon  general  treatment 
and  the  use  of  sponge  tents  just  before  the  expected  time  of  the  men- 
strual period.  I  have  generally  found  that  the  dysmenorrhoea  is 
relieved  in  proportion  to  the  increase  of  the  discharge.  For  this 
purpose,  I  have  employed  one  or  two  tents  before  the  time  for  the 
flow,  or  I  have  made  an  application  of  iodine,  impure  carbolic  acid,  or 
dilute  chromic  acid  to  the  fundus.  Formerly,  I  have  even  passed  up 
a  portion  of  the  solid  nitrate  of  silver,  and  left  it  in  the  canal.  All 
Avith  the  view  of  bringing  on  a  discharge  of  blood  as  a  consequence  of 


TREATMENT    OF    D YSMENORRIICEA.  195 

the  irritation  thus  established.  The  nitrate  of  silver  I  would  not  re- 
commend, even  if  it  were  more  efficient,  for  fear  of  its  after  effects  on 
the  OS.  To  the  use  of  the  chromic  acid,  somewhat  of  the  same  objec- 
tion exists,  although  to  a  much  less  degree,  but  it  is  an  agent  never  to 
be  employed  if  there  is  still  to  be  detected  any  evidence  of  the  products 
of  a  former  cellulitis  remaining.  Under  the  same  circumstances,  the 
use  of  sponge  tents  would  be  equally  admissible.  But  as  long  as  any 
tenderness  or  pressure  can  be  detected  by  the  aid  of  the  finger,  our 
local  means  must  be  limited  chiefly  to  the  use  of  Churchill's  iodine. 
This  injunction  is  only  applicable  to  a  previous  existence  of  cellulitis, 
but,  as  I  have  stated,  it  is  important  that  this  condition  should  not  be 
mistaken  for  the  extreme  reflex  sensitiveness  found  with  impaired  nu- 
trition. If  we  are  able  to  distinguish  the  latter  condition,  there  would 
be  no  danger  in  the  use  of  tents  ;  but  a  few  applications  of  iodine, 
with  glycerine  dressings  afterwards,  may  be  of  service  for  diminishing 
the  sensitiveness  beforehand.  The  iodine  is  to  be  applied  with  the 
applicator,  bent  to  the  exact  course  of  the  canal,  after  this  has  been 
ascertained  by  careful  use  of  the  probe.  To  obtain  the  full  benefit 
the  cotton  saturated  with  the  iodine  must  be  left  behind  in  the  canal 
until  thrown  out  by  the  uterus.  As  soon  as  sponge  tents  can  be 
used  with  safety,  they  should  be  resorted  to  as  the  most  efficient 
means  for  bringing  on  the  flow  and  for  increasing  its  quantity. 

The  membranous  form  of  dysmenorrhoea  is  to  be  treated  locally  in 
the  same  manner,  and  by  the  use  of  sponge-tents  previous  to  the  ex- 
pected period,  when  even  they  can  be  borne. 

As  I  have  already  stated,  I  believe  the  condition  of  scanty  and 
painful  menstruation,  the  utervis  being  of  normal  size,  and  the  mem- 
branous form  of  dysmenorrhoea,  to  be  but  diff"erent  degrees  of  the 
same  state  of  general  impairment  by  which  the  normal  changes  in  the 
uterine  membrane  are  retarded.  By  pressure  of  the  sponge  tent,  or 
by  a  stimulating  application  to  the  uterine  canal,  before  the  expected 
period,  we  hasten  the  disintegration  of  its  lining  membrane,  so  that 
its  condition  is  made  to  approach  nearer  to  a  state  of  health  at  the 
time  when  the  flow  comes  on.  It  may  be  necessary  to  employ  some 
form  of  anodyne  to  allay  irritability  wdien  using  the  tents,  but  remedies 
of  this  class  must  be  used  with  great  care,  to  avoid  creating  the  habit, 
and  on  account  of  their  effect  on  the  digestion.  Under  all  circum- 
stances, the  permanent  gain  will  be  in  proportion  to  any  improvement 
we  may  be  able  to  bring  about  in  the  general  condition.  Frequently 
the  uterus  is  so  irritable  that  the  use  of  hot-water  injections,  with  the 
free  application  of  iodine  to  the  vaginal  walls,  and  a  careful  general 


196         ABNORMAL    CHANGES    IN    THE    MENSTRUAL    FLOW. 

treatment  will  be  necessary  before  an  attempt  can  be  made  to  introduce 
the  tents.  Sometimes  the  patient  is  so  run  down,  and  in  so  irritable 
a  condition,  that  nothing  can  be  accomplished  without  an  entire  change 
of  climate,  and  the  alterative  influence  of  a  sea  voyage. 

For  some  time  after  the  uterus  has  passed  into  a  state  of  atrophy, 
a  woman  will  often  continue  to  suffer  from  backache,  as  has  been 
stated,  at  the  time  when  the  flow  should  make  its  appearance.  I 
have  but  little  faith  in  the  use  of  local  means  for  the  relief  of  this 
condition,  and  there  is  a  limit  even  within  which  any  improvement  in 
the  general  health  will  benefit  the  local  condition. 

Electricity  has  apparently  been  beneficial  sometimes  in  bringing 
on  the  flow-  and  in  relieving  the  pain  caused  by  the  suppression.  But 
the  application  has  been  empirical  in  my  hands,  since,  under  appa- 
rently similar  circumstances,  the  interrupted  current  seemed  sometimes 
to  answer,  when  the  constant  one  had  no  effect.  Sometimes  the 
reverse  of  this  would  be  true,  and  in  turn  both  currents  would  fail. 
Electricity,  in  any  form,  has  usually  a  tonic  influence,  acting  appa- 
rently on  the  general  system,  with  very  little  local  effect,  at  least  in 
diseases  of  women.  Beyond  this  my  experience  does  not  warrant 
a  more  decided  opinion  as  to  the  best  mode  by  which  the  agent  should 
be  used. 

Case  I. — About  two  years  and  a  half  ago,  I  was  consulted  in  refer- 
ence to  the  condition  of  a  young  lady  in  this  city,  with  the  following 
history:  During  childhood  she  had  been,  as  it  was  termed,  rather 
delicate,  but  always  free  from  any  special  difficulty.  She  was  re- 
markably quick  and  intelligent  as  a  child,  Avith  a  great  fondness  for 
study.  She  began  menstrual  life  at  fourteen  years  of  age,  apparently 
under  auspicious  circiimstances,  with  the  flow  lasting  three  days  and 
free  from  pain.  But,  as  a  consequence  of  over-study,  I  have  every 
reason  to  believe,  the  menstrual  flow  became  scanty,  painful,  and 
irregular,  since  the  ovaries  and  uterus  had  become  blighted  before 
she  had  reached  the  age  of  fifteen.  For  nearly  three  years  she  had 
been  traveling  about,  with  great  improvement  to  her  general  health. 
But  there  had  been  no  return  of  the  menstrual  flow,  except  when  it 
so  happened  that  the  period  was  passed  at  sea.  Yet  she  had  fre- 
c],uently  suffered,  at  other  times  on  land,  when  the  flow  should  have 
come  on,  from  a  dragging  feeling  in  the  back,  and  one  of  fulness 
about  the  pelvis.  She  was  eighteen  years  and  a  half  old  when  I  first 
saw  her,  and  her  uterus  was  only  two  inches  deep.  I  could  discover  no 
special  condition  likely  to  be  benefited  by  local  treatment,  so  requested 
Dr.  llockwell  to  take  charge  of  her,  and  try  the  efficacy  of  electricity. 
No  direct  application  was  made  to  the  uterus,  but  the  current  was 
formed  by  placing  one  electrode  over  the  lumbar  region  or  sacrum, 


VICARIOUS    MENSTRUATION.  197 

and  the  other  on  the  lower  portion  of  the  abdomen.  This  treatment 
was  continued  for  some  five  months,  and,  I  believe,  three  times  a 
week,  until  June  28,  1<ST5,  when  she  menstruated  naturally  for  two 
days.  I  made  an  examination  shortly  afterwards,  and  found  that  the 
uterus  hail  ac(^uired  its  normal  size.  The  treatment  by  electricity 
was  shortly  afterwards  modified  as  to  frequency,  but  was  still  ad- 
ministered sufficiently  often  to  keep  up  the  normal  size  of  the  uterus. 
But,  I  believe  there  was  only  one  natural  effort  afterwards,  since  which 
she  has  never  menstruated  except  while  at  sea.  In  the  mean  time,  it 
had  been  so  arranged  that  she  should  sail  a  day  or  two  before  a  men- 
strual period,  and  return  home  at  the  end  of  one  month,  so  that  she 
should  pass  two  consecutive  periods  at  sea.  This  has  been  done  three 
times,  and  in  each  instance  the  flow  has  come  on  naturally,  with  but 
little  pain,  and  has  lasted  two  or  three  days,  but  there  has  been  no 
show  at  home.  She  remains  in  very  fair  general  health,  but  at  times 
is  listless  and  unable  to  interest  herself  in  any  subject  without  making 
an  effort.  Her  general  appearance  is  that  of  a  girl  of  sixteen,  and 
she  has  a  vagina  so  small  that  I  would  have  been  reluctant  to  make 
an  attempt  to  introduce  a  sponge  tent,  even  if  the  necessity  for  one 
had  been  imperative.  As  she  herself  has  wished  this  mode  of  treat- 
ment deferred,  it  has  not  been  urged,  and  the  case  is  cited  chiefly  to 
show  the  effects  of  a  sea-voyage  in  such  cases,  and  this  one  is  not 
unique,  since  I  have  known  of  several  other  like  instances.  Among 
emigrants,  however,  a  contrary  effect  is  produced  by  the  sea-voyage, 
amenorrhoea  being  a  common  condition  for  several  months  after  their 
arrival.  In  the  first  case,  nutrition  being  at  fault,  the  impression 
produced  by  the  sea  air  and  motion  is  beneficial ;  but  with  the  emi- 
grant, who  is  generally  in  good  health,  the  nervous  system  is  fully 
occupied,  from  the  first,  in  counteracting  the  deleterious  effects  arising 
from  anxiety  of  mind,  a  new  mode  of  life,  and  the  privations  to  which 
emigrants  are  too  often  subjected. 


Vicarious  Menstruation. 

It  may  be  reasonably  supposed,  as  habit  plays  so  important  a  part 
in  organic  life,  that  from  this  influence  a  flow  of  blood  to  the  pelvis 
would  take  place  at  regular  intervals,  in  correspondence  with  what 
should  be  the  menstrual  period.  Yet,  there  must  be  a  limit  to  this 
influence,  and  the  supposition  is  a  rational  one  that  the  period  is 
due  to  ovarian  excitement,  so  long  as  the  uterus  remains  of  a  normal 
size.  When  the  uterus  does  remain  of  a  natural  size,  and  the  men- 
strual flow  does  not  take  place  at  the  regular  period,  we  can  but 
suppose  that  the  fault  lies  in  the  uterus  itself.  With  our  present 
limited  knowledge,  we  must  confess  our  ignorance  as  to  the  cause, 
and   can   only  renew  the    supposition,  already  advanced,  that   this 


198        ABNORMAL    CHANGES    IN    THE    MENSTRUAL    FLOW. 

escape  of  blood  cannot  take  place  until  the  uterine  lining  membrane 
has  undergone  the  requisite  change.  If  this  were  proved  true,  Ave 
would  still  have  to  seek  an  explanation  as  to  why  this  change  does 
not  take  place  or  is  delayed,  and  can  only  conceive  the  omission  to 
be  due  to  faulty  nutrition.  When  the  walls  of  the  pelvis  have 
become  over-charged  with  blood,  rupture  of  a  vessel,  as  in  the  forma- 
tion of  hematocele,  would  take  place,  if  no  other  outlet  were  offered. 
Under  the  circumstances,  it  is  supposed  that  this  state  of  recent 
congestion  causes  a  sufficient  local  irritation  to  bring  about  a  reaction. 
The  consequence  is,  the  excess  of  blood  is  thrown  back  upon  some 
other  organ  or  portion  of  the  body,  for  an  outlet,  and  its  escape  at 
the  menstrual  period,  by  an  unnatural  channel,  is  termed  vicarious 
menstruation. 

An  unnatural  escape  of  blood  may  thus  take  place  from  the  mucous 
membrane  of  any  portion  of  the  body,  or  the  pressure  on  the  circula- 
tion may  be  relieved  by  an  unusual  increase  of  the  natural  secretion 
from  some  organ.  But  we  are  ignorant  by  what  law  the  selection  is 
regulated,  so  that  bleeding  of  the  nose,  or  hemorrhage  from  the  stomach 
or  lungs  may  take  place  with  some  individuals,  while  with  others  there 
will  be  a  profuse  serous  diarrhoea.  The  occurrence  of  diarrhoea  at 
this  time  is  common,  and  the  escape  of  blood  from  hemorrhoids  equally 
so  with  some  women,  who  suffer  from  a  scanty  menstrual  flow  ;  and  the 
explanation  is  a  simple  one  when  we  consider  the  connection  between 
the  pelvic  circulation  and  that  of  the  mesentery. 

During  the  temporary  suppression  of  the  menstrual  flow,  from  any 
cause,  the  occurrence  of  diarrhoea  is  often  observed  at  the  time  when 
the  flow  of  blood  should  have  taken  place.  An  increase  of  leucor- 
rhoeal  discharge  from  the  vagina  is  equally  common,  and  is  easily 
understood  to  be  an  effort  of  nature  to  relieve  the  pelvic  congestion  by 
a  ready  outlet,  as  from  a  safety-valve.  But  why,  instead  of  these, 
the  brain  or  vessels  of  the  spinal  column  should  sometimes  bear  the 
brunt,  or  a  periodical  hemorrhage  occur  from  the  stomach,  with  no 
evidence  of  local  disease,  cannot  be  so  readily  explained. 

The  treatment  of  vicarious  menstruation  must  depend,  in  a  general 
way,  on  circumstances.  But  our  chief  efforts  must  be  directed  to  cor- 
recting the  local  condition,  that  the  current  may  as  soon  as  possible 
be  turned  into  the  natural  channel,  before  the  serious  comj^lication  of 
a  bad  habit  becomes  fully  established. 


CAUSES    OF    HYSTERIA.  199 


Hysteria. 


The  various  nervous  manifestations  Avhich  are  grouped  together 
under  the  term  Hysteria  are  all,  as  a  rule,  intimately  associated 
with  some  menstrual  disorder.  These  nervous  manifestations  are 
generally  found  in  the  unmarried  and  sterile,  and  at  puberty,  before 
the  system  has  become  impressed  Avith  the  menstrual  habit.  They 
also  occur  with  the  state  of  ammenorrhoea  or  suppression,  scanty  and 
painful  menstruation,  and  at  the  change  of  life.  These  conditions  are 
associated,  more  or  less,  with  a  general  impaired  nutrition  and  defec- 
tive ovarian  influence.  Hysteria  is  supposed  by  many  to  be  caused 
directly  by  ovarian  irritation,  but  while  granting  that  hysteria  and 
ovarian  disorders  generally  do  coexist,  I  am  not  disposed  to  admit 
a  necessary  relation  of  cause  and  effect.  The  state  of  ovarian  irri- 
tation, or  defectiv^e  action,  and  the  different  nervous  disturbances  are 
equally  affected  by  faulty  nutrition,  as  well  as  the  various  conditions 
enumerated  above,  and  all  spring  from  defective  action  in  the  nerve 
centres. 

This  subject,  as  to  supposed  cause  and  effect,  together  with  the 
general  treatment,  has  already  been  considered.  It  is  only  necessary 
to  state,  in  addition,  that  after  the  shock  or  morbid  impression  has 
been  once  made  on  the  nerve  centres,  it  requires  but  a  slight  exciting 
cause  to  bring  on,  at  any  time,  these  nervous  manifestations,  until  the 
general  tone  has  been  improved.  Defective  nerve  force  would  neces- 
sarily associate  hysteria  with  the  various  conditions  cited ;  and  the 
continuance  of  a  local  difficulty,  depending  on  any  of  these  conditions, 
may  eventually,  by  reaction  on  a  susceptible  nervous  system,  excite, 
at  any  time,  the  nervous  manifestations.  The  treatment  of  hysteria 
consequently  can  be  but  palliative,  and  it  is  necessary  to  combat  its 
symptoms  as  they  may  be  presented,  from  whatever  provocation,  in 
order  to  restore  the  general  and  local  condition  to  a  normal  standard. 

Experience  has  taught  us  that  a  threatened  attack  of  hysteria  may 
often  be  aborted,  or,  if  already  under  way,  may  be  greatly  mitigated 
by  getting  rid  of  the  sudden  generation  of  flatus  in  the  large  intes- 
tines. This  accumulation  is  the  result  of  reflex  irritation  readily 
excited  from  the  close  connection  existing  between  the  nervous  system 
of  the  organs  of  generation  and  the  intestinal  tract.  The  usual  mode 
of  treatment  is  to  administer,  by  injection  into  the  rectum,  the  greater 
portion  of  the  contents  of  a  basin  of  hot  water,  to  which  has  been 
added  an  ounce  of  the  tincture  of  assafoetida.     But  to  cut  short  the 


200        ABNORMAL    CHANGES    IN    THE    MENSTRUAL    FLOW. 

attack,  it  is  absolutely  necessary  to  rouse  the  patient  by  some  powerful 
moral  impression,  through  which  the  physician  will  be  able  to  control 
her,  and  as  she  will  remain  deaf  to  all  reason,  the  influence  can  only 
be  gained  through  fear  or  by  exciting  her  indignation.  Between  two 
paroxysms,  the  patient  will  generally  be  lying  exhausted,  with  her 
head  near  the  edge  of  the  bed,  and  apparently  unconscious.  I  seize 
this  opportunity  to  mix  the  assafoetida  by  stiring  it  up  thoroughly  with 
the  hot  water  in  close  proximity  to  her  nose.  As  she  shifts  her  posi- 
tion to  avoid  it,  the  basin  must  be  moved  accordingly,  until  vomit- 
ing is  induced,  or  a  protest  is  called  forth  to  the  indignity  thus 
offered.  I  then  propose  a  compromise,  to  remove  the  cause  of  offence 
if  she  will  make  the  effort  to  control  herself;  but  on  the  slightest 
evidence  that  an  attack  is  about  to  come  on,  the  mixture  is  held  to 
her  nose  until  the  threatened  paroxysm  subsides,  even  if  she  has  to 
inhale  the  odor  for  hours.  I  then  have  her  placed  on  the  left  side 
near  the  edge  of  the  bed,  with  her  lower  limbs  flexed,  as  if  for  the 
purpose  of  having  the  speculum  introduced,  and  the  injection  is 
administered.  It  is  advisable  to  fill  the  whole  colon,  that  the  bowels 
may  be  thoroughly  moved,  and  the  flatus  all  absorbed  by  the  water, 
or  passed  off.  By  placing  the  patient  in  this  position,  a  much  larger 
portion  of  the  injection  can  be  introduced  than  in  any  other  way,  before 
she  will  feel  any  inconvenience.  The  injection  must  be  thrown  in 
slowly,  and  when,  apparently,  the  patient  is  unable  to  retain  more,  a 
kind  word  of  encouragement  will  aid  her  in  resisting  the  effort  of  ex- 
pulsion. The  nozzle  of  the  syringe  must  then  be  withdrawn,  and  firm 
pressure  be  made  over  the  anus  by  the  palm  of  the  hand  against  a 
napkin  rolled  up  and  placed  between  the  limbs.  Pressure  thus  pro- 
perly made  will  aid  the  patient  in  resisting  the  desire  to  evacuate  the 
bowels,  which  should  be  delayed  as  long  as  possible.  As  the  patient  is 
exhausted,  it  is  best  that  the  bowels  should  be  evacuated  on  a  bed-pan, 
since  the  exertion  of  getting  up  might  bring  on  another  attack,  not- 
withstanding her  efforts  to  resist  it.  By  the  time  the  colon  has  been 
emptied,  the  skin  will  be  acting  well,  and  the  patient,  although 
thoroughly  tired  out,  will  feel  relieved.  The  action  of  the  skin  should 
be  kept  up  by  extra  bedclothing,  and  the  patient  allowed  to  sleep. 
When  the  physician  is  called  early  enough,  he  may  sometimes  prevent 
a  threatened  attack  by  placing  a  mustard  plaster  along  the  whole 
length  of  the  spine,  and  giving  a  dose  or  two  of  tlie  valerianate  of 
ammonia  and  some  good  advice  as  to  her  responsibility.  On  the  other 
hand,  the  attack  may  have  advanced  so  far  that  the  patient  is  no 
longer  able  to  make  any  exertion,  and  it  would  be  necessary  to  apply 


HYSTERIA.  201 

the  mustard  to  the  spine  and  inside  of  the  thighs,  before  the  injection 
could  be  administered.  Sometimes  the  convulsions  are  so  severe  or 
frequent,  it  becomes  necessary  to  administer  an  amesthetic,  so  that, 
while  under  its  influence,  the  hot  water  and  assafoetida  may  be  thrown 
into  the  rectum,  when  also  the  mustard  may  be  applied. 

When  the  colon  is  distended  by  hot  water,  this  reflex  irritation  is 
always  relieved  with  more  promptness  than  if  the  water  were  thrown 
into  the  vagina,  while  the  assafostida  has  also  a  soothing  effect,  and 
both  agents  excite  the  muscular  fibres  to  contract  with  more  tone,  and 
to  resist  afterwards,  for  a  time,  the  accumulation  of  flatus. 

It  is  probable  that  the  rapid  generation  of  flatus,  which  will  some- 
times take  place  within  a  few  seconds,  is  excited  by  the  same  irrita- 
tion causing  the  hysterical  attacks.  We,  however,  learn  from 
observation,  that  the  severity  of  the  paroxysms  is  always  in  pro- 
portion to  the  degree  of  accumulation,  and  that  their  occurrence  can 
be  controlled  by  insuring  a  free  escape  of  flatus,  Avhile  relief  is  ob- 
tained when  the  colon  has  been  thoroughly  emptied. 

It  was  formerly  my  practice  to  have  a  rectal  tube  introduced  by 
the  nurse  as  soon  as  an  attack  was  threatened,  and  I  have  often 
witnessed  an  effect  analogous  to  that  claimed  from  opening  the 
trachea,  by  which  the  free  passage  of  air  arrests  an  attack  of  epilep- 
tic convulsions.  When  the  rectum  happens  to  be  free  from  feces,  on 
introducing  a  large  flexible  tube  to  or  beyond  the  sigmoid  flexure, 
I  am  often  amused  at  the  suddenness  with  which  all  preparations 
for  an  attack  cease.  As  soon  as  the  patient  gets  herself  in  posi- 
tion for  an  attack,  and  tightens  the  abdominal  muscles,  a  free  escape 
of  flatus  takes  place  from  the  tube  without  the  slightest  Avaming,  and 
the  eff"ect  is  that  she  lies  quiet,  fearing  to  move,  and  her  face,  if 
she  is  conscious,  expresses  no  little  surprise. 

Case  II. — Several  years  ago  I  was  present  on  such  an  occasion,  in 
my  private  hospital,  where  a  young  lady  had  been  lying  in  apparently 
an  unconscious  state,  after  an  hysterical  convulsion,  and  had  taken  no 
notice  of  my  presence,  although  I  felt  satisfied  that  she  was  aware  of 
it.  The  nurse  had  just  introduced  the  rectal  tube  as  I  entered  the 
room,  and  the  patient  began  an  attack  shortly  afterwards  for  my 
benefit.  She  suddenly  thrcAv  herself  in  the  position  of  opisthotonos, 
but  before  her  head  and  feet  could  be  brought  under  her,  a  loud 
escape  of  flatus  took  place  from  the  tube,  and  continued  with  a  steady 
rhythm  but  lowering  note  for  several  seconds,  as  she  gradually 
straightened  herself  out,  and  the  colon  became  empty.  I  was  in  a 
position  to  see  her  as  she  opened  her  eyes,  and  the  appearance  of 
astonishment  and  mortification  depicted  on  her  face,  as  the  flatus  con- 


202         ABNORMAL    CHANGES    IN    THE    MENSTRUAL    FLOW. 

tinued  to  escape,  was  intense.  I  quietly  asked  if  she  had  lost  all  the 
delicacy  of  her  sex,  in  making  such  an  exhibition  before  me,  when 
she  burst  into  tears  and  covered  her  face.  She  had,  before  coming 
under  my  care,  been  very  willful,  and  had  had  these  attacks  of  hys- 
teria frequently,  often  tearing  the  bedclothing  and  her  nightgown. 
But  they  were  never  repeated,  as  she  was  assured  by  the  nurse  that 
the  instrument  would  again  be  introduced  if  she  showed  any  symp- 
toms of  another  seizure,  and  after  that  she  would  have  to  continue 
wearing  it,  so  that  the  Avind  might  escape  all  the  time.  Through  this 
fear,  she  began  to  exercise  her  self-control,  and  the  impression  thus 
made  on  her  mind  was  the  turning  point  in  her  case  towards  recovery. 


ABSENCE    AND    ATRESIA    OF    VAGINA.  203 


CHAPTER  XI. 

CONGENITAL  ABSENCE  AND  ACCIDENTAL  ATRESIA  OF  THE  VAGINA  ; 
MODE  OF  OPERATING  FOR  ESTABLISHING  THE  CANAL,  AND  FOR 
EVACUATING  RETAINED  MENSTRUAL  BLOOD. 

Causes  of  retention — Mode  of  relief — Table  XIII.,  exhibiting  cases  of  imperforate 
hymen,  congenital  absence  of  uterus,  and  accidental  occlusion — Cause  of  death 
when  the  uterus  has  been  emptied  of  its  contents — Proper  mode  of  treatment — 
Cases. 

The  retention  of  menstrual  blood  within  the  uterine  cavity  results 
from  cono-enital  or  accidental  causes. 


Causes  of  retention,  - 


^  .,  ,      f  Absence  of  the  vao;ina, 

Confiremtal,    <(  -^         <.      ,    i 

I  Impertorate  hymen. 

f  Closure  of  the  os  uteri, 
Accidental,    <        ,,       cc    cc 


A  young  girl  may  reach  and  pass  the  average  age  for  puberty, 
apparently  in  full  physical  development,  and  yet  withovit  any  appear- 
ance of  the  menstrual  flow.  The  history  given  will  be  to  the  effect  that 
a  year  or  two  previous  to  seeking  advice  all  the  rational  signs  of 
approaching  menstruation  had  been  recognized.  Month  after  month 
these  symptoms  presented  themselves  with  marked  periodicity,  but 
without  a  show  until,  at  length,  the  backache  and  sense  of  pressure 
on  the  bladder  and  rectum  had  become  constant.  Recently,  however, 
these  symptoms  may  not  have  presented  themselves  with  as  much 
regularity,  but  with  a  marked  increase  of  nervous  disturbance  ;  her 
general  health  will  have  already  begun  to  suffer,  and  in  all  probability 
some  symptoms  of  blood  poisoning  may  be  detected  at  the  first  ex- 
amination. 

On  the  other  hand,  with  many  of  these  symptoms  presenting,  there 
may  be  less  inconvenience  from  pressure  on  the  bladder  or  rectum, 
but  with  a  marked  increase  in  the  nervous  disturbance. 

It  is  of  the  greatest  importance  to  investigate  the  condition  of  a 
young  girl  presenting  these  symptoms,  without  delaying  until  her 
general  health  has  begun  to  suffer.  The  chief  point  to  be  established 
by  an  examination  is  whether  or  not  there  exists  retention  of  the 
menstrual  blood,  for  without  this  knoAvledge  we  cannot  be  sure  of  the 


20-i  ABSENCE    OF    THE    VAGIXA. 

proper  course  of  treatment.  The  retention  should  be  recognized 
at  as  early  a  day  as  possible,  since  the  immediate  beneficial  results 
from  any  operative  procedure  will  be  in  proportion  to  the  distension  to 
which  the  uterus  has  been  subjected.  When  the  retention  has  resulted 
from  an  imperforate  hymen,  delay  is  unnecessary,  although,  occasion- 
ally, nature  brings  relief  by  rupture  of  the  membrane.  With  con- 
genital absence  of  the  vagina,  a  resort  to  some  surgical  interference 
is  absolutely  necessary  for  relief,  if  an  accumulation  has  taken  place. 
Nature  guards  against  rujDture  of  the  uterine  wall  by  an  increased 
thickness,  as  during  pregnancy  ;  the  original  parietes  of  the  organ 
are  not  made  thinner  by  the  distension.  As  a  result  of  delay,  the 
patient  becomes  exposed  to  two  dangers :  dilatation  of  the  Fallo- 
pian tubes,  it  is  said,  may  occur  by  their  becoming  filled  with  the 
contents  of  the  uterus,  and  they  may  either  rupture  or  allow  of  the 
escape  of  the  fluid  into  the  peritoneal  cavity.  The  second  and  chief 
danger  is  from  blood  poisoning.  There  is  also  a  risk  from  inflamma- 
tion, in  consequence  of  the  fluid  being  forced  through  the  tissues  of 
the  uterus  without  actual  rupture.  Dr.  Barnes,^  after  referring  to 
some  experiments  by  Br.  Mathews  Duncan,  shoAving  that  under 
hydraulic  pressure,  air  and  liquids  penetrate  the  uterine  wall,  writes: 
"But  it  appears  to  me  that  there  is  good  reason  to  believe  that  the 
force  which  the  living  uterus  exerts  in  its  efforts  to  expel  what  may 
be  in  it,  whether  it  be  a  foetus  or  imprisoned  fluids,  is  enough  to  driv^e 
fluid  through  its  walls,  in  the  form  of  a  fine  oozing,  or  dew,  which 
hangs  on  the  peritoneum.  It  seems  to  me  probable  that  it  is  in  this 
way  that  some  cases  of  puerperal  pelvic  peritonitis  are  produced  ;  and 
I  have  seen  cases  of  septicaemia  and  peritonitis  occurring  from  re- 
tention of  menstrual  fluid,  greatly  resembling  puerperal  fever,  in  which 
there  was  no  rupture,  and  no  escape  of  fluid  by  the  open  ends  of  the 
Fallopian  tubes." 

In  the  absence  of  the  vagina,  it  is  proper  to  open  the  canal  at  an 
early  age,  even  if  no  retention  exists,  or  if  a  vestige  of  the  uterus  can 
be  detected.  A  case  will  be  cited  showing  that  nature  had  evidently 
delayed  the  development  of  puberty  in  consequence  of  there  being  an 
occlusion,  although  this  is  not  the  rule.  Another  instance  will  be  given 
in  which  the  uterus  became  developed,  after  failure  of  the  operation 
to  disclose  any  trace  of  the  organ.  In  two  other  instances,  the  health 
became  established  after  the  operation,  although  no  development  of 

•  A  Clinical  History  of  tlie  Medical  and  Surgical  Diseases  of  Women,  by  Robt. 
Barnes,  M.D.,  i>.  181. 


RETENTION  OF  MENSTRUAL  BLOOD.  205 

the  uterus  took  place  afterwards,  and  this  remarkable  circumstance 
has  also  been  noticed  by  Dr.  Barnes. 

For  the  examination,  the  patient  must  be  placed  on  the  back,  with 
her  limbs  flexed,  and  the  body  Avithin  easy  reach  of  the  operator. 
By  passing  the  index  finger  into  the  rectum,  it  will  be  easy  to  satisfy 
one's  self  from  the  size  of  the  uterus,  if  developed,  as  to  the  probability 
of  retention  within  its  cavity.  This,  however,  we  must  not  assume, 
without  further  examination,  if  the  vagina  be  developed,  since  preo-. 
nancy  has  sometimes  occurred  before  the  appearance  of  menstruation. 
Should  the  uterus  be  felt  in  position,  and  nearly  of  a  normal  size,  it 
will  not  be  necessary  to  extend  the  examination  beyond  separating  the 
labia  for  the  passage  of  a  probe  to  a  sufficient  depth  to  ascertain  that 
the  vagina  is  pervious.  Under  these  circumstances  we  may  assume 
that  the  delay  in  the  appearance  of  the  menses  is  due  to  some  fault 
in  the  general  system,  and  we  must  first  resort  to  means  for  relievino- 
that  condition. 

We  shall  be  able,  as  a  rule,  readily  to  distinguish  the  absence  or  a 
defect  of  the  uterus  from  a  want  of  development  as  to  size  only.  At 
a  point  somewhat  lower  than  that  usually  occupied  by  the  cervix  and 
vaginal  junction,  the  finger  will  come  in  contact  with  a  well-defined 
crescentic  ridge,  or  band,  extending  across  the  pelvis  in  the  direction 
from  one  ovary  to  the  other.  The  sensation  conveyed  to  the  finger 
will  be  that  of  a  sagging  of  the  broad  ligament  or  other  structure  in 
the  space,  which  would  have  been  occupied  by  the  uterus  if  it  had  been 
present.  After  introducing  a  steel  sound  into  the  bladder,  the  ex- 
tremity of  the  instrument  can  be  easily  brought  into  contact,  along  this 
crescentic  band,  with  the  finger  in  the  rectum,  which  could  not  be 
done  at  this  point  were  the  uterus  in  position. 

According  to  Kussmaul  and  others  it  rarely,  if  ever,  happens  that 
the  uterus  is  entirely  wanting,  and  they  hold  that  a  post-mortem  ex- 
amination Avill  always  reveal  some  vestige  or  rudimentary  portion  of 
it.  The  correctness  of  this  statement  I  cannot  verify  or  disprove  by 
post-mortem  observation,  but  I  have  seen  six  cases  or  more  of  con- 
genital absence  of  the  vagina  where,  after  the  most  careful  investiga- 
tion, it  was  impossible  to  detect  the  slightest  trace  of  the  uterus. 

When  the  accumulation  is  confined  to  the  uterine  cavity,  the  elastic 
body,  as  felt  from  the  rectum,  will  be  nearly  globular  in  shape.  But 
the  most  common  form  met  with  is  the  one  shown  in  Fig.  42,  where 
a  portion  of  what  is  a  recto-vesical  septum  is  also  distended.  No 
portion  of  the  vaginal  canal  is  open,  but  the  tissue  which  presents 
at  the  OS  is,  when  this  becomes  dilated,  crowded  off"  and  put  on  the 


206 


ABSENCE    OF    THE    VAGINA, 


stretch,  as  the  fluid  continues  to  accumulate.  It  is  sometimes  stated 
by  writers,  that  the  uterine  cavity  does  not  become  dilated  when  the 
accumulation  has  been  caused  by  an  imperforate  hymen.  The  correct- 
ness of  this  statement  depends  upon  the  extent  of  accumulation,  since 
the  uterus  must  become  dilated  by  the  backing  up  of  the  fluid  as 
soon  as  the  vagina  becomes  over-distended,  or  if  there  should  be  no 
other  outlet. 

Fis:.  42. 


Absence  of  vagina,  and  retained  menstrual  blood. 


With  young  girls  who  have  never  had  a  menstrual  show,  the  ob- 
struction is  usually  a  congenital  one,  due  to  a  want  of  development 
of  the  vaginal  canal,  in  whole  or  in  part ;  or  the  retention  may  be 
caused  by  an  imperforate  hymen.  There  are  exceptions,  however, 
to  this  rule,  for  instances  are  not  uncommon  where  the  vagina 
has  become  closed  up  in  childhood,  from  some  injury  or  from  in- 
flammation of  the  mucous  membrane.  The  first  condition  is  a  con- 
sequence of  the  introduction  of  some  foreign  body  into  the  canal, 
by  Avhich  sloughing  and  contraction  followed.  Of  this  form  of  injury 
an  instance  will  be  cited,  where  the  passage  was  destroyed  in  a  young 
child  by  her  falling  on  a  dead  branch  of  a  tree,  which  entered  the 
vagina  and  penetrated  into  the  abdominal  cavity  through  the  poste- 
rior cul-de-sac.     The  second  condition,  as  a  consequence  of  inflarama- 


RETENTION  OF  MENSTRUAL  BLOOD.  207 

tion  of  the  mucous  membrane,  may  be  produced  by  exposure  to  cold 
or  neglect  of  cleanliness.  But  this  form  of  adhesive  inflammation 
seldom  extends  throughout  the  canal,  and,  unless  sloughing  has 
occurred,  it  docs  not  offer  so  persistent  an  obstacle  to  the  final  escape 
of  the  fluid  which  may  have  been  retained  by  it ;  but  it  frequently 
leaves  the  passage  constricted. 

The  external  portions  of  the  organs  of  generation  are  generally  well 
formed,  but  on  exposing  the  vulva,  the  orifice  of  the  urethra  will  be 
found  rather  lower  than  natural,  and  at  the  bottom  of  a  shallow  sulcus, 
and  there  will  be  no  appearance  of  a  vaginal  outlet.  In  absence  of 
the  vagina,  the  urethra  is  always  unnaturally  relaxed,  but  the  power 
of  retention  of  urine  remains  uninjured.  I  have  placed  on  record^  a 
case  of  this  description,  where  a  young  woman,  after  having  been 
married  several  years  without  a  menstrual  show,  consulted  me  for  the 
latter  difficulty.  I  found  not  the  slightest  evidence  of  the  existence 
of  a  uterus  nor  trace  of  the  vagina,  but  I  discovered  that  connection 
had  been  carried  on  through  the  urethra  into  the  bladder,  without 
either  husband  or  wife  having  suspected  the  true  condition. 

Accidental  occlusion  of  the  vagina  is  a  frequent  consequence  of 
child-bearing,  from  sloughing  caused  by  long-continued  pressure  at 
some  one  point,  or  throughout  the  canal.  Strong  injections  of  the 
nitrate  of  silver  and  other  agents,  as  used  formerly  for  the  treatment 
of  leucorrhoea,  have  frequently  caused  closure  of  the  passage  by 
adhesive  inflammation.  By  the  application  of  various  caustics  to  the 
upper  portion  of  the  vagina,  and  particularly  by  the  use  of  the 
galvano-cautery  for  amputating  the  cervix,  the  os  becomes  closed, 
with  retention  of  menstrual  blood  following. 

Unless  the  injury  is  received  at  an  early  age,  it  seldom  happens 
that  the  passage  becomes  destroyed  throughout  its  course,  from  any 
accidental  cause,  or  that  the  vaginal  outlet  ever  becomes  so  entirely 
changed  as  to  present  only  a  shallow  sulcus  between  the  labia,  as  in 
congenital  absence  of  the  vagina.  Some  aid  may  be  gained  for 
formincr  a  diamosis  from  the  thickness  of  the  septum  between  the 
bladder  and  rectum,  and  this  is  to  be  ascertained  by  means  of  a  finger 
in  the  rectum  and  a  sound  in  the  bladder.  In  the  congenital  form, 
the  septum  will  be  found  as  thin  as  the  recto-vesical  one  in  the  male, 
since  there  has  been  no  development  of  the  muscular  and  other  tissues 
forming  the  vaccinal  wall.  But  after  the  vagina  has  been  once  formed, 
and  the  uterus  has  for  a  while  performed  its  functions,  the  vaginal 
wall  will  remain,  after  accidental  occlusion,  even  thicker  than  before, 

•  Vesico-yaginal  Fistula  from  Parturition  and  other  Causes,  etc.,  p.  229. 


208 


ABSENCE    OF    THE    VAGINA. 


SO  that  there  will  be  little  difficulty  in  forming  an  opinion,  even  if  the 
presence  of  the  uterus  could  not  be  detected.  Under  ordinary  cir- 
cumstances, there  can  be  but  little  difficulty  in  forming  an  accurate 
idea  of  the  true  condition.  In  the  absence  of  a  vagina,  with  accumu- 
lation, the  condition  might  be  complicated  by  the  occurrence  of  a 
hematocele  or  a  collection  of  pus  in  the  pelvis,  but  a  careful  investiga- 
tion of  the  case  will  remove  all  such  difficulties  of  diagnosis. 

But  it  may  sometimes  be  almost  impossible,  except  after  frequent 
examination,  to  determine  the  exact  condition  where  a  double  uterus 
exists  with  a  single  vagina,  or  a  double  uterus  and  double  vagina,  as 
seen  in  Fig.  43.     Some  years  ago,  I  was  consulted  by  a  woman 


Fi-.  43. 


Double  uterus  and  double  vagina,  with  retention. 

about  nineteen  years  of  age,  who  had  never  menstruated  regularly, 
and  wished  relief  from  a  sense  of  pressure  and  bearing  down  which 
had  existed  for  several  years.  She  was  exceedingly  nervous.  I  had 
great  difficulty  in  completing  a  thorough  examination,  and  was  not 
a  little  puzzled  to  make  out  a  diagnosis.  To  the  left  of  the  vagina 
there  was  felt  an  accumulation  of  fluid  extending  as  high  as  the  finger 
could  reach,  and  from  the  rectum  an  elastic  and  nearly  globular  body 
could  be  felt  closely  attached  to  the  uterus.  After  satisfying  myself 
as  to  the  position  of  the  fluid  and  its  connection  with  the  uterus,  I 
unfortunately  proposed  to  introduce  an  exploring  trocar  to  ascertain 
the  character  of  the  accumulation.  It  seemed  I  had  already  lost  my 
patient's  confidence  from  the  length  of  time  I  had  taken  to  form  an 
opinion  as  to  what  her  difficulty  was,  so  that  my  proposition  was 


RETENTION  OF  MENSTRUAL  BLOOD.  209 

refused  on  the  ground  that  she  would  not  be  experimented  with  any 
longer;  I  never  saw  the  case  again,  and  know  nothing  of  her  sub- 
sequent history. 

Owing  to  ray  connection  with  the  Roosevelt  hospital,  I  was  recently 
called  into  consultation  to  see  a  case  in  the  institution  under  the 
charge  of  Dr.  Watts,  one  of  the  visiting  physicians.  In  this  case 
there  were  two  vaginas,  but  the  uterus,  or  uteri,  only  opened  into  the 
passage  where  the  accumulation  took  place.  The  other  canal  lay  in 
the  median  line,  and  terminated  above  in  a  cul-de-sac,  and  was  the 
one  by  which  sexual  intercourse  had  taken  place,  since  the  mouth 
of  the  vagina  which  led  to  the  occluded  uterus  Avas  exceedingly  small 
and  to  one  side,  and  was  only  detected  by  accident.  The  patient  was 
not  aware  of  her  condition,  but  had  consulted  Dr.  Watts  for  the  re- 
moval of  her  sterility.  Dr.  Watts  afterwards  operated  by  dividing 
the  septum  and  converted  the  two  passages  into  a  single  one.  There 
existed  sufficient  similarity  between  these  two  cases  for  me  to  assume 
that  the  condition  represented  in  Fig.  43  as  that  of  my  patient  Avas 
a  correct  one  for  both.  There  existed  a  double  uterus  and  vagina, 
with  one  canal  closed,  as  if  from  an  imperforate  hymen.  She  was 
not  regular  as  regards  an  external  floAv  of  blood,  since  she  never  had 
a  show  with  a  less  interval  than  two  months,  so  that  it  is  likely  the 
two  uteri  menstruated  alternately. 

Unless  the  retention  be  due  to  an  imperforate  hymen,  or  to  some 
slight  barrier  resulting  from  adhesive  inflammation,  nature  is  power- 
less to  relieve  herself.  All  writers  agree  as  to  the  danger  attending 
a  long  retention  of  the  menstrual  fluid,  and  are  equally  in  accord  as  to 
the  risk  to  life  for  the  woman  from  any  procedure  instituted  for  the 
purpose  of  evacuating  the  contents  of  the  distended  uterus. 

In  consequence  of  the  many  fatal  results  which  followed  the  early 
operations  for  making  a  vaginal  tract,  more  recent  operators  have 
resorted  to  tapping  the  uterine  cavity  with  a  trocar  from  the  rectum, 
and  various  modifications  of  the  instrument  all  have  reference  to  ex- 
cluding the  air.  But  experience  has  demonstrated  that  the  danger 
to  the  patient  is  equally  great  after  tapping  from  the  rectum,  and  as 
the  procedure  cannot  give  permanent  relief,  the  operation  for  opening 
a  vagina  is  now  received  with  more  favor.  But  it  is  now  generally 
considered  advisable  that  the  canal  should  not  be  completed  at  once, 
and  that  the  opening  should  be  a  very  small  one,  so  that  the  contents 
of  the  uterus  may  be  drawn  off"  slowly,  in  order  to  guard  against  the 
fluid  being  forced  by  uterine  contraction  through  the  Fallopian  tubes 
into  the  abdominal  cavity.  My  own  experience  has  taught  me  to 
14 


210  ABSENCE    OP    THE    VAGINA. 

follow  a  course  entirely  at  variance  with  that  recommended  by  the 
best  authorities,  which  is  essentially  the  same  as  that  adopted  by  the 
early  operators. 

In  the  London  Lancet,  August  13,  1831,  a  review  is  given  of  a 
recent  work^  by  Mr.  R.  Fletcher.  Among  other  operations,  one  is 
cited  for  opening  a  passage  to  the  uterus  in  a  married  woman  twenty- 
two  years  of  age,  who  had  never  menstruated,  and  where  sexual  inter- 
course had  taken  place  through  the  urethra.  It  is  stated  that  after 
the  first  cut,  made  with  a  scalpel  to  the  depth  of  some  two  inches, 
fearing  to  continue  by  that  method,  he  introduced  into  the  wound  a 
large  rectal  bougie,  Avhich  he  advanced  from  time  to  time  by  taps 
from  a  mallet.  "  In  about  a  week,  repetitions  of  this  practice  of 
tapping  succeeded  in  reaching  what  proved  to  be  the  uterus,  which 
was  perfectly  formed,  and  in  a  healthy  condition."  This  woman  soon 
afterwards  menstruated,  and  at  the  time  of  recording  the  case  she  had 
already  become  the  mother  of  two  children. 

This  novel  method  of  opening  a  passage  does  not  seem  to  have  been 
repeated,  yet,  from  the  character  of  the  tissue,  which  separates  so 
readily,  between  the  walls  of  the  bladder  and  rectum,  the  method  is 
one  which  might  be  resorted  to  with  advantage.  When  the  septum 
is  thin,  by  steadying  the  parts  with  two  fingers  in  the  rectum,  the 
bougie  will  encounter  less  resistance  from  the  cellular  tissue  than 
from  the  walls  of  either  cavity.  But  the  operation  could  have  been 
completed,  with  less  risk  to  the  patient,  in  as  many  minutes  as  he 
occupied  days  for  the  purpose. 

Amussat,^  in  1832,  operated  on  a  girl  between  fifteen  and  sixteen 
years  of  age,  who  had  suffered  for  two  years  from  retention.  He 
abandoned  the  use  of  the  knife  after  getting  through  the  skin,  for 
fear  of  entering  the  bladder  or  rectum,  and  separated  the  tissues  by 
the  aid  of  the  nail  and  finger.  After  a  little  advance,  the  wound  was 
packed  with  sponge  for  three  days,  when  the  tearing  process  was 
again  resorted  to,  and  the  wound  refilled  with  sponge.  After  three 
attempts,  the  tumor  was  reached  on  the  tenth  day  and  emptied  by  a 
trocar  and  bistoury.  She  suffered  from  inflammation  of  one  of  the 
Fallopian  tubes,  and  after  being  relieved  four  times  from  retention, 
the  canal  finally  remained  sufficiently  open. 

Previous  to  the  date  of  my  first  operation,  a  few  isolated  cases  'are 
reported  where  efforts  for  relief  had  consisted  in  tapping  from  the 

'  Medico-chinirgical  Notes  and  Illustrations,  part  1st. 
2  Gaz.  Medicale  de  Paris,  1835. 


IMPERFORATE    HYMEN. 


211 


rectum,  or  in  following  the  plan  adopted  hy  Amussat  for  opening  a 
passage  to  the  uterus.  These  cases  were  chiefly  for  accidental  closure, 
and  in  every  instance  the  operation  was  extended  over  several  days, 
and  the  evacuation  made  through  a  small  openino-. 

Table  XIII.  exhibits  the  cases  of  imperforate  hymen,  congenital 
absence  of  the  vagina,  and  accidental  occlusion,  with  retention,  which 
have  passed  under  my  observation. 

Table  XIII — Cases  of  Retention,  due  to  Imperforate  Hymen,  Congenital 
absence  of  the  Vagina,  and  accidental  Occlusion,  with  results  of 
Operation. 


Cause  of  retention 

Remarks. 

Result. 

Private 
Ho.spital. 

Woman's 
Hospital. 

Total. 

Imperforate  hy- 
men. 

Congenital  absence 
of  the  vagina. 

Congenital   ab- 
seuee    of   the    - 
vagina. 

Atresia  of  the  cer- 
vix   from    child- 
birth. 

Atresia  from  trau- 
matic injury. 

Atresia  from  ampu- 
tating the  cervix 
uteri     with     the 
galvanic  cautery. 

Eetention  from  one 
to  two  and  a  half 
years. 

Relieved. 

All  relieved.     Case  in 
Woman's    Hospital 
had  cellulitis. 

Uterus     subsequently 
developed,  and  men- 
struation became  nor- 
mal. 

There  was  no  menstru- 
ation, as  the   uterus 
never  developed. 

All    relieved.       One 
case  had  cellulitis. 

Relieved. 

Relieved   only  tempo- 
rarily ;     atresia     re- 
turned. 

4 
2 

2 

3 

1 
1 

1 
1 

1 

6 

4 

-      7 

9 

1 

1 

No    uterus    found 
after  the    opera- 
tion. 

No  uterus   found. 
Two  married  and 
one  single. 

Menstruation   re- 
tained  several 
times,   necessita- 
ting- several  ope- 
rations. 

Total  number  of 

cases 

13 

9 

22 

I  have  only  met  with  four  cases  of  retention  due  to  imperforate 
hymen.  It  was  impossible  to  determine  with  any  accuracy  the  time 
at  which  the  accumulation  began,  for  in  the  case  which  had  suffered, 
as  it  was  supposed,  for  the  longest  period,  the  amount  of  retained  fluid 
was  less  in  quantity  than  in  another  in  which  the  retention  had  existed 
less  than  a  year.  There  can  be  no  doubt  of  the  fact  that  the  pouring 
out  of  the  first  menstrual  flow  is  delayed  as  long  as  possible  when  an 
obstacle  exists  to  its  free  escape  (as  if  nature  recognized  the  necessity), 
and  after  it  has  become  established,  the  quantity  is  never  so  great  with 
a  congenital  obstruction,  as  when  one  is  formed  by  accident,  later  in 
life.  My  impression  is  that  the  average  accumulation  in  these  cases 
was  about  six  ounces.     I  divided  the  hymen  with  a  sharp-pointed 


212  ABSENCE    OF    THE    VAGINA. 

bistoury,  and  then  freely  enlarged  the  incision  with  my  index  .finger. 
As  soon  as  the  collections  had  escaped,  I  washed  out  the  vagina  and 
the  partially  dilated  uterus  thoroughly  with  warm  water,  by  means  of 
a  Davidson's  syringe.  A  small  glass  vaginal  plug  was  then  introduced, 
and  removed  night  and  morning  for  the  purpose  of  having  the  vagina 
syringed  out.  These  cases  received  no  other  treatment,  except  to  be  kept 
quiet  in  bed  seven  or  eight  days,  and  they  all  recovered  without  the 
slightest  disturbance.  But  for  the  fact  that  cases  have  been  placed  on 
record  where  death  has  resulted  from  this  simple  operation,  I  should 
have  regarded  the  procedure  as  being  worthy  of  little  more  than  a 
passing  recognition. 

By  reference  to  Table  XIII.  it  will  be  seen  that  there  were  seven 
cases  of  congenital  defect  in  the  vagina :  six  with  entire  absence,  and 
one  Avith  a  transverse  septum  higher  up,  as  if  it  were  a  second  hymen, 
about  an  inch  from  the  outlet.  There  existed  retained  menstruation  in 
two  cases  where  the  vagina  was  wanting,  and  in  a  third  where  the 
septum  higher  up  acted  as  the  barrier.  The  fourth  case  of  absence 
of  the  vagina  was  sent  to  the  Woman's  Hospital  after  an  unsuccessful 
attempt  had  been  made  to  open  the  passage.  The  operator  had  cut 
through  a  portion  of  the  urethra  into  the  bladder,  so  that  the  woman 
had  no  longer  any  retentive  power.  The  record  of  this  case  will  be 
given  hereafter,  and  is  one  of  particular  interest  on  account  of  the 
uterus  having  been  developed  after  the  opening  of  the  vagina,  and 
after  our  having  failed  to  detect  the  existence  of  the  organ,  even  in  a 
rudimentary  state,  prior  to  the  operation.  Not  the  slightest  vestige 
of  the  uterus  could  be  detected  in  the  remaining  three  cases  of  con- 
genital absence  of  the  vagina,  nor  was  there  subsequently  any  effort 
of  nature  to  develop  the  organ,  even  if  it  did  not  exist  in  an  unde- 
veloped state. 

Nine  cases  of  accidental  atresia,  following  difficult  labor,  with  reten- 
tion of  the  menstrual  flow  afterwards,  have  passed  under  my  observa- 
tion. The'  history  of  the  only  case  belonging  to  this  class  of  injuries 
which  presented  any  unusual  difficulty  Avill  be  given  to  illustrate  the 
mode  of  treatment,  and  to  establish  the  date  of  instituting  it. 

The  history  of  the  remaining  case  of  accidental  atresia,  resulting 
from  a  traumatic  injury  received  in  childhood,  by  which  the  Avhole  canal 
was  destroyed,  and  puberty  delayed  in  consequence,  will  be  given 
also. 

Early  in  1863  I  received  in  my  private  hospital  a  patient,  1(5  years 
of  age,  who  had  been  suffering  for  a  year  previous  with  all  the  symp- 
toms of  retained  menstruation.    At  the  first  examination  I  ruptured  the 


IMPERFOKATE    HYMEN.  213 

hymen  without  difficulty,  and  just  beyond  it  I  reached  a  thin  septum 
through  -which  I  could  detect  the  evidence  of  fluid  by  making  pres- 
sure with  a  finger  of  the  other  hand  in  the  rectum.  This  was  my  first 
case  of  the  kind,  although  I  had  seen  one  not  unlike  it  in  the  Woman's 
Hospital  in  which  the  fluid  was  evacuated  by  Dr.  Siras^  through  a 
small  opening,  and  the  vagina  enlarged  by  an  operation  a  few  weeks 
subsequent.  I  placed  the  patient  on  her  side,  and  introduced  the 
speculum  until  the  septum  was  brought  into  view,  when,  the  surface 
being  steadied  by  means  of  a  tenaculum,  I  cut  through  it  with  a  pair 
of  scissors.  The  patient  was  then  turned  on  her  back,  and  as  the 
blood  escaped  I  forced  my  finger  through  the  opening  until  the  septum 
was  broken  up.  As  soon  as  the  flow  of  blood  lessened,  I  had  a  bed- 
pan placed  under  her,  and  then  washed  out  the  vagina  and  the  dilated 
uterus  with  warm  water  until  the  water  returned  clear.  A  glass  plug, 
or  dilator,  of  a  proper  size,  was  introduced,  she  was  not  allowed  to  get 
up  for  ten  days,  and  had  no  further  treatment  beyond  the  vaginal  in- 
jections of  w'arm  water  morning  and  evening. 

This  was  not  only  my  first  case  of  retention,  but  the  first  also  in 
which  I  made  a  free  opening,  and  employed  warm-water  injections  to 
wash  away  the  blood  from  the  interior  of  the  uterus  and  vagina.  I 
followed  the  course  which  seemed  to  me  based  on  sound  principles, 
without  the  knowledge,  at  the  time,  that  the  mode  of  treatment  was 
not  the  accepted  one.  Amussat  was  about  the  only  authority  who 
had  Avritten  from  any  experience,  and  if  I  had  then  been  familiar  with 
his  views  they  "would,  in  all  probability,  have  had  but  little  weight, 
since  his  course  was  well  fitted  for  exciting  inflammation  and  blood 
poisoning. 

Shortly  after  treating  the  above  case,  another  with  retention  from 
imperforate  hymen  came  under  my  charge,  and  she  also  was  relieved 
in  the  manner  described.  I  unfortunately  did  not,  at  the  time,  appre- 
ciate the  importance  of  the  operation,  and  failed  to  place  it  on  record, 
but  at  a  subsequent  date  I  reported^  the  three  following  cases, 
on  Avhich  msij  be  based  my  claim  for  a  mode  of  treatment  which 
additional  experience  has  now  shown  to  be  most  successful. 

Case  III. — Mrs.  B.,  of  Newark,  N.  J.,  was  admitted  to  the  Woman's 
Hospital,  April  27,  1863,  with  a  vesico-vaginal  fistula  following  her 
first  labor  of  five  days'  duration  and  forceps  delivery.    Although  three 

'  Reported  in  Clinical  Notes  on  Uterine  Surgery,  p.  337. 

2  Accidental  and  Congenital  Atresia  of  the  Vagina,  etc.,  read  before  the  New 
York  Obstetrical  Society,  June  19,  1866,  and  published  in  the  Richmond  (Va.) 
Medical  Journal,  August,  1866. 


214  ABSENCE  OP  THE  VAGINA. 

years  had  elapsed  since  her  confinement,  there  had  been  no  return  of 
menstruation,  and,  with  extreme  prostration  of  the  nervous  system, 
her  general  health  had  become  much  impaired.  On  introducing  the 
finger  between  the  labia,  at  the  depth  of  less  than  an  inch,  it  passed 
directly  into  the  bladder,  through  a  transverse  fissure  situated  at  its 
neck,  about  two  inches  in  length.  From  the  posterior  margin  of  the 
fistula,  the  vagina  was  entirely  occluded.  Nothing  definite  was 
gained  by  a  rectal  examination  beyond  the  fact  that  pelvic  cellulitis 
had  previously  existed,  and  the  position  of  the  uterus  could  not  be 
detected. 

May  10.  With  the  patient  etherized  and  lying  on  the  back,  two 
deep  incisions  outwards  and  downwards  were  made  on  each  side  of 
the  fourchette,  through  a  dense  cicatricial  band,  involving  this  portion 
of  the  vaginal  outlet.  By  an  assistant,  the  posterior  edge  of  the 
fistula  was  seized  by  means  of  a  tenaculum,  and  being  drawn  upwards 
in  the  direction  of  the  pubes,  was  put  on  the  stretch.  The  vaginal 
tissue  was  then  carefully  divided  laterally  with  a  scalpel,  in  the  sup- 
posed direction  of  the  uterus.  As  the  canal  was  opened  up,  the 
thumb  of  the  left  hand  of  the  operator  was  advanced  to  put  the  poste- 
rior wall  of  the  vagina  on  the  stretch  by  pressure  backwards,  and 
with  two  fingers  of  the  same  hand  in  the  rectum  as  a  guide,  the 
relative  thickness  of  the  rectal  septum  was  preserved.  A  depth  of 
nearly  five  inches  was  gained,  when  the  hemorrhage  became  so  ex- 
cessive that  a  further  attempt  to  reach  the  uterus  Avas  abandoned.  A 
hollow  glass  plug,  five  inches  in  length  by  two  in  diameter,  was  in- 
troduced and  retained  in  situ  by  a  perineal  bandage.  The  patient  was 
placed  in  bed,  and  opium  administered,  after  the  eifects  of  the  ether 
had  passed  off.  For  several  days  she  suffered  much  from  constitu- 
tional disturbance,  irritability  of  the  bladder,  and  a  feeling  of  sore- 
ness over  the  lower  portion  of  the  abdomen.  Retention  of  urine 
resulted  in  consequence  of  the  pressure  exerted,  and,  without  removing 
the  plug,  the  bladder  was  emptied  by  means  of  a  gum-elastic  catheter. 
As  the  plug  had  controlled  the  hemorrhage,  it  was  not  taken  out  for 
several  days,  until  loosened  by  suppuration,  and  afterwards  large 
vaginal  injections  of  tepid  water  were  used  daily  until  her  discharge. 
At  the  end  of  ten  clays,  it  was  found  that  absorption  of  the  tissue  had 
gradually  taken  place  by  pressure  of  the  vaginal  plug,  until  the  cervix 
could  be  felt  through  a  thin  septum,  a  little  to  the  left  and  about  four 
inches  from  the  mouth  of  the  vagina. 

June  3.  The  septum  was  caught  up  on  a  tenaculum,  and  divided 
by  scissors ;  the  vagina,  Avhich  had  been  closed  throughout  by  ad- 
hesions, was  thus  opened,  with  the  exception  of  a  small  cavity  im- 
mediately around  the  cervix  uteri,  into  which  the  latter  protruded 
uninjured. 

2G^/i.  The  artificial  vagina  being  now  properly  healed,  the  edges  of 
the  fistula  Avere  pared  by  scissors,  and  approximated  Avith  eight  in- 
terrupted silver  sutures.  The  edges  of  the  fistida  Avcre  sloping,  as  is 
usually  the  case  Avlicn  situated  at  this  point,  and,  although  two  inches 
long  on  the  vaginal  surface,  receded  until  the  actual  length  of  the 


ACCIDENTAL    OCCLUSION.  215 

opening  was  not  more  than  half  so  much  at  the  entrance  to  the 
bladder.  On  the  ninth  day  the  sutures  were  removed,  and,  with  the 
union  perfect,  she  was  dischai'ged  cured,  July  15. 

Oct.  8.  She  was  re-admitted  to  the  hospital,  in  consequence  of  a 
gradual  closure  of  the  vanrina.  It  was  found  that  the  oriojinal  con- 
dition  of  atresia  existed  to  the  posterior  edge  of  the  closed  fistula, 
Avhich,  however,  had  remained  intact,  with  perfect  control  of  the  urine. 
On  the  next  day,  the  previous  operation  was  repeated,  until  the  os 
was  again  reached,  and  a  glass  plug  of  the  same  size  introduced. 
During  the  night,  she  had  a  violent  chill,  followed  by  an  attack  of 
pelvic  cellulitis.  The  plug  was  removed,  and  at  the  end  of  two  weeks 
she  recovered,  with  closure  again  of  the  vagina  nearly  to  the  original 
condition. 

Nov.  8.  She  was  examined,  and  it  was  found  that  about  an  inch 
had  been  gained.  At  th'e  bottom  of  this  canal,  nearer  to  the  base  of 
the  bladder,  a  small  opening  was  detected,  only  large  enough  to  admit 
an  ordinary  probe.  After  passing  some  two  inches,  its  point  could  be 
felt  from  the  rectum,  in  the  neighborhood  of  the  cervix  uteri.  A 
straight,  blunt-pointed  bistoury  was  passed  along  the  probe  as  a  guide, 
and  on  withdrawing  it,  an  incision  was  made  in  the  median  line,  to  the 
depth  of  half  an  inch,  directly  through  this  septum,  on  the  support 
given  by  the  index  finger  in  the  rectum.  A  similar  incision  was  made 
laterally  to  the  right  and  left,  thus  again  opening  the  canal  to  the 
cervix  uteri,  so  as  to  admit  a  plug  nearly  two  inches  in  diameter.  The 
hemorrhage  was  so  great,  that  it  became  necessary  to  remove  the 
plug,  and  introduce  a  larger  one  into  the  rectum  ;  this  kept  the  cut 
surfaces  in  contact,  and  controlled  the  hemorrhage.  The  opening, 
however,  gradually  contracted,  although  vaginal  plugs  were  used  as 
soon  as  it  was  safe  to  introduce  them. 

Dec.  5.  The  small  sinus  which  still  existed  was  dilated  by  a  sponge 
tent,  so  as  to  admit  the  index  finger,  and  free  incisions  Avere  again 
made  through  the  septum,  for  three  inches  in  length. 

Jan.  9,  1864.  She  returned  home  to  recover  her  health,  having 
just  menstruated  for  the  first  time  since  her  pregnancy,  after  an 
interval  of  nearly  four  years.  The  vaginal  surface  had  become  well 
healed  over  the  plug,  which  had  been  in  use  since  the  operation,  and 
which  was  only  removed  at  the  time  of  receiving  the  daily  injections 
of  tepid  water. 

May  25.  She  Avas  again  admitted,  suffering  from  constant  pain 
and  a  feeling  of  fulness  in  the  pelvis.  There  had  been  no  menstrual 
show  since  leaving  the  hospital,  although  the  nisus  had  been  regular. 
The  use  of  the  plug  had  been  continued,  until  gradually  it  became 
impossible  to  introduce  it  without  great  pain.  The  canal  was  again 
closed.  Through  the  rectum  a  mass,  slightly  fluctuating,  was  detected 
filling  up  the  pelvis,  and,  with  the  other  hand  over  the  abdomen,  the 
uterus  Avas  felt  enlarged  nearly  to  the  umbilicus.  As  it  Avas  near  the 
regular  time  for  menstruating,  she  Avas  kept  in  bed  and  under  the 
influence  of  opium. 

June  6.    In  the  presence  of  some  of  the  members  of  the  American 


216  ABSENCE  OF  THE  VAGINA. 

Medical  Association,  a  trocar  was  passed  from  the  vagina  through 
the  septum,  which  was,  in  consequence  of  the  accumulation  hehind, 
only  an  inch  in  thickness.  More  than  a  quart  of  retained  menstrual 
fluid  was  evacuated,  with  great  relief,  the  opening  was  enlarged,  and 
the  cavity  of  the  dilated  uterus  w^ashed  out  by  injections  of  tepid 
water.^  After  ten  days  the  discharge  all  ceased.  With  the  septum 
so  thin,  and  having  been  freely  divided,  every  hope  of  success  was 
anticipated  in  keeping  it  open  permanently.  In  July  she  was  dis- 
charged, after  menstruating  freely,  and  with  her  general  condition 
much  improved. 

She  returned  to  the  hospital  December  2d,  after  menstruating  each 
month  with  increasing  pain  and  difficulty.  Through  the  septum,  a 
little  over  an  inch  thick,  a  small  sinus  still  remained,  but  only  large 
enough  to  admit  a  probe.  Its  tract  was  somewhat  enlarged  by  a 
bistoury,  and  four  ounces  of  retained  menstiniation  evacuated.  She 
was  placed  under  ether,  and  after  introducing  two  fingers  of  my  left 
hand  into  the  rectum  well  behind  the  mass  as  a  fixed  point,  the  index 
finger  of  the  other  hand  was  forced  with  much  difficulty  through  the 
small  opening.  The  canal  was  opened  by  laceration,  by  the  addition 
of  one  finger  after  another,  until  almost  as  much  was  thus  gained  as 
had  been  previously  done  by  means  of  the  knife.  The  hemorrhage 
was  slight ;  she  was  kept  in  bed  for  a  week,  partially  under  the 
influence  of  opium,  without  any  bad  symptoms  following  the  operation. 
Early  in  January,  18*>5,  she  Avas  discharged. 

Feb.  23.  She  reported  herself  for  examination,  after  menstruating 
twice  without  pain.  The  vagina  was  now  four  and  a  half  inches  deep, 
the  surface  well  healed,  and  with  but  little  discharge.  She  was 
directed  to  continue  the  use  of  the  glass  plug  for  some  time. 

1  lost  sight  of  the  case  until  May  23,  1866,  when  she  visited  the 
hospital.  She  was  in  perfect  health,  regular,  and  living  with  her 
husband  happily.  On  examination,  the  vagina  was  found  well  opened, 
its  parietes  soft  and  perfectly  healed,  although  of  a  much  deeper  color 
than  natural.  The  plug  had  not  been  worn  for  several  months,  and 
was  only  inserted  occasionally  as  a  precaution. 

This  case  is  one  of  great  interest.  Between  May  10,  1863,  and 
December  2,  1864,  she  had  been  operated  on  by  means  of  the  knife 
five  times,  and,  with  the  greatest  care,  gradually  occlusion  occurred 
by  contraction  after  each  operation.  From  December  2,  1864,  when 
the  canal  was  opened  by  laceration,  to  the  present  time  (nineteen 
months),  there  has  been  no  perceptible  change  in  the  size  of  the 
vagina. 2  It  can  scarcely  be  supposed  that  the  canal  would  have 
remained  as  open  had  she  entirely  discontinued  the  use  of  the  plug, 

'  From  the  hospital  register  it  is  shown  that  Drs.  .James  P.  White,  Byford, 
Storer,  T.  F.  Rocliester,  E.  M.  Moore,  S.  H.  Tewksbury,  and  others,  were  present 
at  the  operation,  and  I  have  been  unable  to  find  on  record  tliat  an/  operator, 
previous  to  this  date,  had  washed  out  the  uterus  after  evacuating  retained  men- 
strual blood  tlirough  a  fi'ee  opening. 

2  August  1,  18(J7,  she  reported  herself  in  good  healtli,  and  able  to  live  with  her 
husband  without  difficulty. 


ACCIDENTAL    OCCLUSION.  217 

or  were  she  not  married ;  but  the  point  not  to  be  lost  sight  of  is  that 
under  the  same  circumstances  after  each  of  the  previous  operations, 
the  atresia  became  perfect  in  a  few  Aveeks. 

Case  IA-^. — Oct.  2T,  1864,  Miss  N.,  aged  18,  came  under  my  charge 
as  a  private  patient.  She  was  a  slight,  delicate,  and  apparently  an 
undeveloped  child,  of  not  more  than  twelve  years  of  age.  There  had 
been  no  attempt  at  puberty,  and  I  was  consulted  in  consequence  of 
the  absence  of  menstruation  at  so  advanced  a  period.  The  external 
development  of  the  organs  of  generation  was  found  in  keeping  with 
her  apparent  age.  On  attempting  to  make  an  examination,  I  dis- 
covered that  the  vagina  was  absent,  and  only  a  slight  sulcus  between 
the  labia.  A  sound  was  passed  into  the  bladder,  and  the  index  finger 
of  the  left  hand  into  the  rectum ;  on  an  approximation,  the  intervening 
tissue  Avas  apparently  not  thicker  than  the  vesico-vaginal  tissue  is 
usually  found.  x\fter  a  careful  exploration  per  rectum,  I  detected  a 
small  mass  just  within  reach,  which  I  supposed  to  be  either  a  cornu 
of  the  uterus,  or  the  organ  undeveloped. 

After  questioning  her  mother  carefully,  Ilearned  that  her  daughter 
had  received  an  injury,  Avhen  about  seven  years  of  age,  which  proved 
to  have  had  a  bearing  on  her  case.  She  stated  that  while  running  in 
a  wood,  her  daughter  had  tripped,  over  the  dead  limb  of  a  tree.  In 
falling,  she  ran  a  portion  of  a  bough  into  either  the  rectum  or  vagina, 
and  in  consequence  was  ill  a  long  time  from  "inflammation  of  the 
bowels."  Again  separating  the  labia,  I  detected  a  slight  depression, 
and  at  the  bottom  a  faint  cicatricial  line.  I  determined  to  operate, 
thinking  it  possible  (although  it  is  not  always  the  rule)  that  puberty 
had  been  retarded  in  consequence  of  the  obstruction. 

SQth.  After  a  free  action  of  the  bowels,  she  was  brought  under 
the  influence  of  ether  by  Dr.  Gr.  S.  Winston,  who  assisted  me.  She 
was  placed  on  the  back,  the  lower  extremities  Avell  flexed  on  the 
abdomen,  and  a  sound  passed  into  the  bladder,  to  be  held  by  an, 
assistant.  With  a  pair  of  scissors,  I  carefully  cut  through  the  cica- 
tricial line,  and  with  the  index  finger  the  tissue  was  broken  down  to 
the  depth  of  an  inch.  The  advance  was  now  made  in  the  direction 
of  the  mass  felt  through  the  rectum,  by  sweeping  the  finger  laterally 
to  the  right  and  left,  until  firmer  tissue  was  reached.  When  it  was 
apparent,  by  the  sense  of  touch,  with  a  sound  in  the  bladder,  and  two 
fingers  in  the  rectum  as  a  guide,  that  in  either  direction  the  relative 
distance  was  not  preserved,  pressure  was  made  in  the  opposite  direc- 
tion, until  a  median  course  was  regained.  The  tissue  was  readily 
broken  down,  and  with  little  bleeding ;  the  uterus  was  reached  at  the 
depth  of  three  inches,  in  some  ten  minutes.  The  separation  was 
continued  less  than  an  inch  beyond  the  cervix,  when  the  tissue  became 
so  dense  that  it  was  evident  at  this  point  that  the  peritoneal  cavity 
had  been  entered  at  the  time  of  receiving  the  injury.  The  neck  of 
the  uterus  was  uninjured,  while  the  vagina  had  been  destroyed  up  to 
and  around  the  cervix,  without  involving  it.  The  sound  passed  into 
the  uterine  cavity  an  inch  and  three-quarters. 


218  ABSENCE    OF    THE    VAGINA. 

A  large  glass  plug  was  inti'oduced,  and  retained  by  a  bandage. 
During  the  night  she  was  so  comfortable  that  an  opiate  was  not  re- 
quired ;  not  a  bad  symptom  occurred,  and  at  the  end  of  a  week,  the 
improvement  in  the  condition  of  her  nervous  system  was  remarkable. 
The  vagina  was  daily  syringed  with  tepid  water,  and  all  discharge 
ceased  at  the  end  of  three  weeks.  A  month  after  the  operation  she 
returned  home,  with  an  injunction  to  continue  the  use  of  the  plug  and 
injections  for  several  months,  and,  if  there  was  no  contracting  of  the 
canal,  gradually  to  discontinue  them. 

Three  months  afterwards  she  menstruated  for  the  first  time,  and  so 
rapid  had  been  the  development  of  puberty,  that  several  members  of 
the  family,  I  was  informed,  who  had  not  seen  her  since  the  operation, 
did  not  recognize  her.  After  missing  a  month  she  became  regular, 
and  has  continued  so  in  perfect  health.  I  had  not  heard  of  the  case 
again  until  her  mother  visited  me  from  a  neighboring  State,  on  the 
25th  of  April,  1876,  and  gave  me  the  above  history  of  her  case  after 
her  return  home. 

Case  V. — Miss  K.,  aged  21,  a  private  patient,  consulted  me,  July 
24th,  1865,  having  never  menstruated.  In  appearance  she  was  tall, 
well  formed,  and  apparently  in  good  health.  Since  the  age  of  six- 
teen, -she  had  been  subject  to  sick  headaches,  and  occasionally  to  a 
wearing  pain  low  down  in  the  back,  but  with  no  evidence  of  periodicity, 
as  indicative  of  a  menstrual  nisus.  There  had  been  no  change  in  her 
general  health,  but  during  the  previous  year  she  had  become  nervous 
and  irritable  in  her  disposition. 

On  examining  the  case,  I  discovered  an  entire  absence  of  the  vagina, 
and  by  the  rectum  no  indication  whatever  of  the  uterus.  The  external 
organs  of  generation  were  well  developed,  the  nymphee  unusually 
large,  and  of  a  dark  color.  The  meatus  urinai-ius  was  quite  patulous, 
but  not  so  much  so  as  is  usually  the  case  where  the  vagina  is  con- 
genitally  absent. 

The  young  lady,  unfortunately,  had  been  engaged  to  be  married 
for  several  years,  and  her  parents  were  exceedingly  anxious  that  an 
attempt  should  be  made  to  reach  the  uterus  or  to  settle  the  fact  of  its 
absence.  In  consequence  of  the  warm  weather,  I  delayed  ihe  opera- 
tion until  autumn. 

Oct.  5,  1865.  In  consultation  with  Drs.  Thos.  Cock,  T.  G.  Thomas 
and  Burroughs,  she  was  etherized  and  placed  on  the  back,  with  tlie 
lower  extremities  flexed  on  the  abdomen.  After  snipping  the  tissue 
with  a  pair  of  scissors,  for  nearly  an  inch  in  a  vertical  line  at  the 
bottom  of  the  sulcus  between  the  labia,  the  cellular  tissue  was  lace- 
rated by  means  of  the  nail  and  index  finger,  as  in  the  previous  case. 

High  up  in  the  pelvis,  a  thick  transverse  band  could  be  felt  from 
the  rectum,,  as  if  it  were  a  portion  of  the  broad  ligament  occupying 
the  position  of  the  uterus,  and  stretching  from  one  ovary  to  the  other  ; 
at  this  point  it  sagged  Avithin  reach  of  the  finger.  The  advance  in 
this  direction  Avas  made  Avith  great  care,  in  consequence  of  the  ex- 
treme thinness  of  the  septum,  between  the  bladder  and  rectum.     The 


ABSENCE    OF    VAGINA    AND    UTERUS.  219 

existence  of  any  portion  of  the  uterus  was  the  main  point  to  be  settled ; 
therefore  the  false  passage  was  not  enlarged  laterally  more  than 
enough  to  admit  the  finger  readily.  After  extending  it  to  the  depth 
of  some  three  inches,  an  absence  of  the  uterus  became  so  evident, 
that  in  consultation  it  was  decided  to  discontinue  the  operation.  A 
glass  plug  Avas,  however,  introduced.  The  bleeding  had  been  slight. 
She  Avas  confined  to  bed,  and  sat  up  at  the  end  of  a  week. 

The  disappointment  was  very  great,  and  on  being  questioned 
whether  I  could  be  positive  as  to  the  non-existence  of  the  uterus  from 
the  fact  that  it  was  not  found  in  the  median  line,  I  determined  to 
make  a  thorough  effort  to  settle  the  point,  A  few  days  afterwards, 
with  the  assistance  of  Dr.  John  G.  Perry,  ether  was  administered,  and 
I  proceeded  with  the  operation.  The  false  passage  was  still  over  two 
inches  deep  ;  this  I  enlarged  laterally  with  the  finger,  until  I  reached 
firmer  tissue,  and  could  feel  the  sides  of  the  pelvis,  as  in  an  ordinary 
vaginal  examination.  After  an  advance  of  some  three  inches,  I  began 
to  realize  the  danger  of  continuing  the  lateral  dilatation  to  the  same 
extent,  as  it  was  evident,  from  the  sense  of  touch,  that  the  uterus  was 
wanting,  and  that  the  tissue  was  not  so  dense  beyond.  An  advance 
was  continued,  however,  in  the  median  line  for  an  inch  further,  until 
I  was  satisfied  that  scarcely  three-quarters  of  an  inch  intervened  be- 
tween the  extremity  of  the  finger  in  the  vagina  and  the  edge  of  the 
band  felt  through  the  rectum. 

Two  fingers  were  passed  into  the  rectum,  and,  with  the  aid  of  a 
hand  over  the  abdomen,  nothing  could  be  ascertained  as  to  the  exist- 
ence of  the  ovaries.  High  up  on  the  right  side  a  mass  was  indistinctly 
felt,  but  it  seemed  too  distant  for  the  ovary,  and  there  Avas  nothing  to 
correspond  on  the  opposite  side.  My  impression  was,  that  they  were 
either  entirely  wanting,  or  in  an  undeveloped  state. 

It  Avas  remarkable,  for  such  an  operation,  that  the  bleeding  should 
have  been  so  slight,  and  confined  chiefly  to  the  breaking  down  of  the 
surfaces  already  well  healed.  A  plug,  a  little  over  four  inches  long 
by  tAvo  in  diameter,  Avas  inserted. 

During  the  night  the  stomach  continued  irritable  from  the  effects  of 
the  ether,  and  she  was  restless,  with  a  pulse  of  108.  Before  daylight, 
an  opiate  enema  Avas  administered,  and  repeated  in  three  hours  after- 
w^ards.  She  became  quiet,  and  tAventy-four  hours  after  the  operation 
she  Avas  A^ery  comfortable.  Beyond  the  use  of  vaginal  injections  and 
anodynes  Avhen  needed,  she  received  no  further  treatment.  At  the 
end  of  ten  days  she  sat  up,  but  her  convalescence  was  so  tedious  that 
she  Avas  not  strong  enough  to  return  home  until  Nov.  21th. 

I  saw  her  occasionally  in  the  interval,  until  June  15th,  1866.  I 
then  made  a  careful  examination,  both  by  the  rectum  and  vagina,  but 
there  Avas  no  further  indication  of  the  existence  of  either  uterus  or 
ovaries.  The  vagina  was  as  capacious  as  at  the  time  of  returning 
home,  after  the  operation  ;  its  parietes  were  soft  and  of  a  natural 
color,  except  on  the  rectal  septum  about  an  inch  from  the  fourchette, 
where  I  found  several  indolent-looking  excrescences,  to  which  nitrate 


220  ABSEXCE    OF    THE    VAGINA. 

of  silver  was  applied.  The  plug,  for  several  months,  had  not  been 
used  with  any  regularity,  and  only  passed  occasionally  at  night.  She 
was  in  her  usual  good  health,  free  from  all  vaginal  discharge,  but  still 
nervous  and  easily  excited.  During  the  past  eight  months  there  had 
been  nothing  in  her  condition  which  would  indicate  any  menstrual 
nisus. 

This  case,  apart  from  the  interest  bearing  upon  the  subject  under 
consideration,  is  an  anomalous  one.  As  a  Avell  developed-female, 
with  this  single  exception,  without  any  vicarious  discharge,  her  gene- 
ral health  is  excellent,  while  there  is  no  indication,  at  present,  of 
chlorosis,  phthisis,  or  any  organic  disease.  The  condition  of  her 
nervous  system  may  be  hereditary  to  a  certain  extent,  for  her  mother 
is  of  the  same  temperament. 

The  subsequent  history  of  this  case  is  of  interest.  During  Septem- 
ber, 1866,  she  married,  as  the  vagina  had  become  healed  with  a  surface 
closely  resemabling  mucous  membrane.  The  dilator  had  been  intro- 
duced with  efficient  regularity  to  keep  open  the  passage,  and  I  could 
detect  but  little  if  any  change.  The  marriage  was  contracted  with 
the  full  understanding  of  both  parties  that  there  was  scarceh"  a  possi- 
bility that  even  a  rudimentary  uterus  existed,  and  that  the  probabili- 
ties were  that  the  canal  would  gradually  close.  I  heard  nothing  of 
her  after  her  marriage  until  early  in  May,  1874,  when  I  met  her  acci- 
dentally on  a  visit  to  one  of  her  relatives  who  was  under  my  charge. 
I  had  not  an  opportunity  to  make  an  examination,  but  she  stated  to  me 
that  her  married  life  had  been  a  happy  one,  and  she  was  not  conscious 
that  any  material  change  had  taken  place  in  the  size  of  the  passage. 
I  could  see  no  change  in  her  appearance  except  that  she  had  aged 
somewhat  beyond  her  years  and  had  become  less  nervous. 

Case  VI. — Miss  L.  0.  consulted  me  Oct.  27,  1870,  on  the  recom- 
mendation of  her  physician.  Dr.  Zakryewska,  of  Boston.  Her  age 
was  17,  and  she  had  never  menstruated,  although  for  two  years  pre- 
vious, there  had  been  every  month  an  increase  of  backache,  nervous 
disturbance,  and  feeling  of  pressure  in  the  pelvis.  The  uterus  Avas  dis- 
tended, as  well  as  a  small  portion  of  the  vagina,  or  rather  posterior 
cul-de-sac,  for  from  the  rectum  a  marked  transverse  depression  could 
be  felt  along  the  junction  of  the  vagina  and  uterus.  Fluctuation  was 
detected  in  the  rectum  by  making  pressure  with  the  other  hand  on 
the  fundus  through  the  abdominal  wall. 

Nov.  1.  After  the  patient  had  been  placed  under  the  influence  of 
ether,  I  opened  a  passage,  about  three  inches  deep,  to  the  uterus,  and 
evacuated  between  eight  and  nine  ounces  of  menstrual  blood,  which 
presented  the  usual  characteristics,  in  being  free  from  odor,  and  in 
possessing  a  tardike  consistency.  The  uterine  cavity  was  washed  out 
thoroughly  with  warm  water,  a  glass  dilator  introduced,  and  the  case 
treated  in  other  respects  by  the  method  above  described.  After 
menstruating  twice  without  difficulty,  she  returned  home  about  the 
middle  of  February,  1871,  with  the  vagina  open  and  healed.     With 


CONGENITAL    OCCLUSION, 


221 


Occlusion  of  the  vagina. 


the  exception  of  a  slight  febrile  action  on  the  third  day,  there  had  not 
been  the  slightest  disturbance  during  the  progress  of  the  case. 

April  18,  1873.  She  reported  herself  for  examination,  having 
been  in  excellent  health  and  menstruating  regularly.  On  examination, 
I  found  an  hour-glass-shaped  con- 
traction of  the  vagina  at  about  half 
an  inch  in  front  of  the  cervix, 
through  -which  the  index  finger 
could  be  passed  -with  difficulty. 
The  seat  of  constriction  was  situ- 
ated at  A  B(see  Fig.  14),  and  cor- 
responded with  the  point  at  which 
the  opening  was  made  at  the  time 
of  the  operation  between  the  new 
passage  and  the  upper  portion  of 
the  vao;ina,  then  distended  with 
blood. 

15th.  I  freely  divided  this  en- 
circling band  Avith  a  bistoury,  and 
the  surface  healed  over  a  glass  di- 
lator before  she  returned  home.  I  have  not  had  the  opportunity  for 
an  examination  since,  but  have  recently  ascertained  that  the  vagina 
still  remains  somewhat  constricted  at  this  point,  but  Avithout  entailing 
any  inconvenience  upon  her. 

Case  VII. — Miss  D.  R.  Avas  admitted  to  the  Woman's  Hospital  Dec. 
13,  1870.  The  previous  history  of  this  case  is  obscure,  as  recorded, 
from  the  statement  made  by  the  patient  that,  after  the  performance 
of  some  operation  by  her  physician,  she  menstruated  several  times 
at  the  age  of  fifteen  and  sixteen.  A  long  interval  then  elapsed  with- 
out a  show,  until  after  a  fit  of  illness  and  a  profuse  discharge  of  pus 
Avith  hemorrhage,  when  she  had,  at  regular  intervals,  several  men- 
strual periods,  as  they  Avere  thought  to  be.  About  four  years  pre- 
vious to  admission  an  attempt  had  been  made  to  open  a  vagina,  but 
apparently  Avithout  the  operator  taking  the  precaution  to  introduce  a 
sound  into  the  bladder  and  his  finger  into  the  rectum,  to  serve  as 
guides,  since  an  opening  was  made  into  the  bladder,  from  Avhich  she 
afterAvards  had  incontinence.  About  one-third  of  the  urethra,  and 
the  base  of  the  bladder  for  nearly  an  inch  beyond  the  neck,  had  been 
laid  open.  The  raAV  surfaces  had  been  constantly  coated  with  a  phos- 
phatic  deposit  from  the  urine,  so  that  the  parts  remained  as  patu- 
lous as  after  the  accident,  and  the  finger  could  be  introduced  into  the 
bladder  without  difficulty.  By  the  aid  of  the  index  finger  in  the 
bladder,  and  another  in  the  rectum,  I  was  unable  to  detect  a  trace  of 
the  uterus.  There  had  evidently  been,  at  some  time,  extensive  cellu- 
litis to  the  left  and  in  the  neighborhood  of  the  region  which  should 
have  been  occupied  by  the  uterus.  Judging  from  the  thickness  of  the 
recto-vesical  septum,  the  case  Avas  regarded  as  one  of  congenital 
absence  of  the  vagina,  if  not  also  of  the  uterus.     Until  March  10, 


222  ABSEXCE  OF  THE  VAGINA. 

the  time  -was  occupied  in  getting  the  parts  healed,  and  in  a  proper 
condition  for  an  operation,  while,  in  the  interval,  on  five  different 
occasions,  with  and  without  ether,  a  most  careful  investigation  had 
been  made  without  gaining  any  additional  information.  It  was 
deemed  advisable  to  close  first  the  opening  into  the  bladder,  before 
attempting  the  operation  for  forming  a  new  vagina.  After  great 
difficulty,  from  its  being  at  the  bottom  and  to  one  side  of  a  deep  cone, 
the  fistula  was  closed  by  ten  interrupted  sutures.  Two  days  after- 
wards, she  had  an  attack  of  peritonitis,  and  on  the  16th  of  March  her 
life  was  considered  in  jeopardy.  Reaction  took  place,  however,  and 
on  the  24th  she  Avas  well  enough  to  have  the  sutures  removed ;  bub 
shortly  afterwards  the  surfaces  separated,  leaving  the  pai'ts  in  their 
former  condition.  Her  convalescence  was  tedious  until  May  20, 
when  she  was  discharged  with  instructions  to  return  in  the  following 
autumn. 

Readmitted  December  10,  18T1,  with  her  general  health  much  im- 
proved, and  with  the  statement  that,  for  several  months  past,  she  had 
suffered  at  regular  intervals  with  symptoms  of  a  menstrual  nisus.  Her 
condition  was  not  yet  one  to  Avarrant  any  surgical  interference,  and 
she  continued  to  remain  under  observation.  March  19, 1872,  she  had 
a  show  of  bloody  urine,  but  it  had  ceased  before  I  could  examine  her 
condition.  May  3  a  recurrence  of  the  bloody  urine  took  place,  but 
no  further  information  could  be  gained,  beyond  the  fact  that  the  escape 
of  blood  was  from  some  point  within  the  bladder. 

June  7.  While  under  ether,  a  thorough  exploration  was  made  by 
Dr.  Sims  and  myself.  A  small  body  Avas  then  detected,  for  the  first 
time,  but  we  were  unable  to  determine  the  question  of  its  identity  with 
the  undeveloped  uterus.  AVith  a  scalpel,  I  made  some  advance  in  that 
direction,  when  I  opened  into  a  small  sinus  through  Avhich  the  sound 
was  passed  to  so  great  a  depth  that  I  supposed  I  had  entered  one  of 
the  ureters  just  beyond  its  entrance  into  the  bladder.  Xo  further 
attempt  was  made,  and  on  June  12  she  was  sent  home. 

Feb.  10,  1873.  On  her  retura,  ether  was  administered,  and  by 
the  rectum,  the  finger  without  difficulty  detected  the  uterus,  now 
nearly  of  a  normal  size.  K.  small  sinus  was  found,  as  the  result  of 
the  previous  operation,  in  the  vagina.  Along  this  a  probe  was  intro- 
duced, and  its  course  enlarged  by  means  of  scissors  and  by  lacerating 
the  tissues.  A  passage  Avas  then  continued  beyond  in  the  direction 
of  the  uterus,  until  the  os  was  reached,  into  Avhich  the  probe  Avas 
passed  to  the  fundus.  A  glass  dilator  Avas  used  for  a  fcAV  days,  Avhen 
it  had  to  be  abandoned,  in  consequence  of  the  irritation  it  produced 
and  a  threatened  attack  of  cellulitis.  The  index  finger  Avas  carefully 
passed  several  times  a  day  to  the  cervix,  that  the  canal  might  be 
prevented  from  contracting,  and,  Avith  frequent  injections  of  hot  water, 
the  parts  Avere  kept  free  from  the  irritating  effects  of  the  urine.  AVhen 
healed  she  returned  home. 

April  15.  The  fistulous  opening  into  the  bladder  was  closed  by 
tAvelve  sutures.  So  much  disturbance  resulted,  Avith  threatened  cellu- 
litis and  irritation  of  the  bladder,  that  she  had  to  be  kept  constantly 


CONGENITAL    OCCLUSION.  223 

under  the  influence  of  opium,  and  the  bladder  carefully  washed  out 
twice  a  day  by  means  of  a  double  catheter. 

May  1.  The  sutures  were  removed,  and  the  union  was  found 
perfect. 

June  10.  I  learned  that  a  slight  escape  of  urine  took  place  when 
walking,  but,  after  a  careful  examination,  it  was  found  due  to  the 
condition  of  the  urethra,  which  had  been  drawn  backward  by  contrac- 
tion of  the  cicatricial  surface  in  the  vagina.  The  vaginal  canal  had 
shortened  very  much  in  consequence  of  this  contraction,  but  the  calibre 
was  yet  sufficient  to  admit  the  passage  of  the  finger  to  the  uterus,  and 
the  result,  under  the  circumstances,  was  considered  an  excellent  one. 
She  Avas  discharged,  to  return  again. 

March  12,  1874.  She  Avas  readmitted.  Her  general  health  had 
become  established,  the  retention  of  urine  was  perfect,  and  she  had 
menstruated  regularly,  with  the  flow  lasting  four  days,  and  rather  free 
in  quantity. 

May  26.  The  vagina  was  enlarged  as  much  as  was  deemed  pru- 
dent, without  the  risk  of  setting  up  a  fresh  cellulitis,  which,  it  was 
possible,  might  have  followed  if  carried  too  far,  since  the  remains  of 
the  previous  attack  were  still  to  be  detected.  She  was  afterwards 
discharged,  to  return  at  some  future  time,  for  the  purpose  of  having 
the  vagina  thoroughly  opened  in  case  she  contemplated  marriage,  or 
if  contraction  sufficient  to  obstruct  the  escape  of  menstrual  flow  should 
take  place. 

Three  years  have  now  elapsed  since  her  discharge,  and  I  am  igno- 
rant of  her  present  condition. 

Case  VIII. — Miss  A.  L.,  aged  fifteen  and  a  half  years,  was  admitted 
to  the  Woman's  Hospital  March  4,  1876.  She  had  never  menstru- 
ated, but  eight  months  previous  to  admission  she  began  to  suffer  for 
the  first  time  from  pain  at  the  hypogastrium,  lasting  from  two  to  three 
days.  Since  the  first,  the  pain  had  returned  regularly  every  month, 
with  increasing  severity  and  duration.  Only  a  few  days  previous  to 
admission  she  had  passed  through  one  of  these  periods  of  suffering 
which  had  lasted  ten  days.  Her  general  health  was  poor,  and  she 
bad  a  marked  strumous  appearance.  The  external  organs  of  genera- 
tion were  well  developed,  but,  on  separating  the  labia,  a  sulcus  was 
seen  terminating  in  the  urethra.  By  placing  the  hand  over  the  ab- 
domen, and  an  index  finger  in  the  rectum,  an  elastic  mass  was  felt 
like  the  uterus  at  the  fifth  month  of  gestation.  The  case  was  evidently 
one  of  retained  menstruation  due  to  congenital  absence  of  the  vaginal 
outlet,  with  the  upper  portion  of  the  vagina  distended,  as  in  Case  VI. 

March  14.  While  under  ether,  the  skin  was  snipped  with  a  pair  of 
scissors,  in  a  vertical  line  below  the  urethra.  The  patient  had  been 
previously  placed  on  the  back  with  her  lower  limbs  flexed  on  the 
abdomen.  A  steel  sound  was  then  passed  into  the  bladder  and  held 
by  an  assistant  on  the  left  of  the  patient.  I  introduced  two  fingers  of 
the  left  hand  into  the  rectum  as  a  guide,  and  between  them  and  the 


224  ABSENCE    OF    THE    VAGTXA. 

sound  separated  rapidly  the  cellular  tissue,  by  means  of  the  finger 
nail,  until  I  had  made  an  opening  about  an  inch  in  depth.  The  open- 
ino;  ^vas  then  freelv  enlaro-ed,  by  Avorkino;  the  finder  to  the  riaiht  and 
left ;  after  this  the  advance  was  made  by  sweeping  my  finger  from 
one  side  of  the  pelvis  to  the  other.  This  was  readily  done,  as  there 
had  been  no  cellulitis,  and,  if  I  felt  that  I  was  getting  too  near  either 
the  bladder  or  rectum,  I  would  make  pressure  downward  or  upward 
until  I  got,  as  it  were,  into  another  stratum.  After  advancing  about 
two  inches  and  a  quarter  in  the  median  line,  the  septum  between  my 
finger  and  the  fluid  had  been  reduced  to  a  few  lines  in  thickness. 
Through  this  I  introduced  a  small  trocar,  and  drew  off  some  twenty- 
four  ounces  of  fluid.  The  puncture  was  then  enlarged  by  introducing 
a  pair  of  scissors,  and  the  parts  were  lacerated  by  opening  the  blades. 
The  finger  was  then  passed,  and  a  free  opening  made.  The  uterus 
was  thoroughly  washed  out  with  hot  water  by  passing  the  long  nozzle 
of  a  Davidson's  syringe  up  into  the  cavity.  To  the  last  quart  or  two 
of  the  water  a  little  carbolic  acid  had  been  added.  A  large  glass 
dilator  was  then  introduced.  The  patient  did  well  for  twenty-four 
hours,  when  the  pulse  rose  to  116,  and  the  temperature  to  102°, 
with  headache,  this  being  her  only  complaint. 

16th.  It  was  directed  that  she  should  have  the  injections  every 
three  hours,  with  carbolic  acid  added,  as  the  discharge  had  become 
free,  and  had  some  odor.  Five  grains  of  quinine  were  ordered  every 
four  hours.  She  still  complained  of  headache,  and  felt  chilly,  but 
there  was  no  marked  rigor.  At  2  P.  M.  her  pulse  rose  to  136,  and 
the  temp,  to  103.7°.  At  8  P.  M.  the  pulse  was  140  per  minute, 
while  the  temperature  had  lowered  to  100.2°. 

11th.  The  discharge  had  become  quite  abundant,  of  a  brownish 
color,  and  still  slightly  fetid.  Her  stomach  was  disturbed,  and  she 
vomited  several  times  during  the  night.  At  8  A.  M,  the  pulse  was 
120,  and  temp.  101°  ;  at  3.30  P.  M.  pulse  was  130,  and  temperature 
101.5°. 

ISth.  Her  condition  was  decidedly  better,  and  she  began  to  con- 
valesce. 

19th.  There  was  a  slight  relapse ;  the  temperature  at  102.6° 
during  the  night,  and  a  return  of  the  headache. 

2()th.  Detected  marked  tenderness  over  the  lower  portion  of  the 
abdomen,  and  especially  to  the  left  side,  w^ith  tympanites.  This  was 
discovered  after  she  had  had  a  movement  of  the  bowels  from  an 
enema. 

2Sd.  I  made  an  examination  by  the  rectum,  and  found  cellulitis 
on  the  left  side,  extending  behind  the  uterus.  I  directed  that  a 
shorter  vaginal  plug  should  be  used,  for  I  ascertained  that,  from  the 
second  day,  the' nurse  had  had  difficulty  in  passing  the  plug  into  the 
upper  portion  of  the  vagina.  I  found  the  canal  constricted  at  this 
point,  as  shown  in  Fig.  44,  Case  YL,  and  I  had  no  doubt  that  if  the 
cellulitis  was  not  actually  produced  by  her  efforts  to  force  the  dilator 
through,  its  extent  was  at  any  rate  increased  by  the  irritation. 


ACCIDENTAL    OCCLUSION.  225 

2Ath.  I  directed  that  the  use  of  the  dilator  should  be  abandoned, 
but  the  vaginal  injections  were  to  be  continued  several  times  a  day. 

2oth.  During  the  night  she  had  several  loose  and  fetid  movements 
from  the  bowels,  Avhich  were  examined  by  the  microscope,  and  found 
to  consist  almost  entirely  of  pus.  She  was  placed  on  milk-punch, 
cod-liver  oil,  quinine,  and  iron. 

2Sth.  The  abdominal  tenderness  and  tympanites  were  found  de- 
creasing rapidly,  and,  by  the  microscope,  but  little  pus  was  detected 
in  the  feces.  She  gradually  convalesced,  but  was  not  strong  enough 
to  be  discharged  until  May  10.  She  had  not  menstruated  since  the 
operation,  but  this  was  scarcely  to  be  looked  for  in  her  reduced 
condition. 

June  20,  1876.  She  reported  herself  at  the  hospital  for  examina- 
tion. Her  general  health  had  been  improving  slowly,  but  menstruation 
had  not  returned. 

Feb.  1877.  She  again  visited  the  hospital,  having  regained  her 
health,  and  menstruating  regularly.  I  found  the  upper  portion  of 
the  vagina  in  front  of  the  uterus  so  constricted  that  J  was  scarcely 
able  to  pass  the  index  finger.  The  canal  below  had  changed  but  little. 
She  will  return  at  some  future  time,  when  the  canal  will  be  enlarged. 
It  should  be  noted  that,  at  the  time  this  operation  was  performed,  the 
atmosphere  of  the  hospital  had  become  so  bad  from  a  defect  in  the 
sewerage,  which  was  not  discovered  until  afterwards,  that  no  serious 
operation  had  been  performed  for  several  weeks,  and  the  defect  was 
at  that  time  reported  to  have  been  remedied. 

Case  IX. — Feb.  13,  1874,  I  saw  Mrs.  H.,  in  consultation  with 
Dr.  James  L.  Little.  She  was  a  woman  of  thirty-two  years  of  age, 
the  mother  of  six  children,  the  youngest  being  three  years  old. 
Seventeen  months  after  the  birth  of  her  last  child,  the  cervix  had 
been  removed  by  the  galvanic  cautery  for  supposed  malignant  disease. 
She  suffered  afterwards  from  cellulitis,  and,  in  all  probability,  from 
peritonitis,  so  that  she  was  confined  to  her  bed  for  five  months  after 
the  operation,  and  had  never  regained  her  health.  If  the  diagnosis 
was  a  correct  one,  the  disease  was  most  thoroughly  eradicated,  for  I 
found  the  vagina  only  about  an  inch  and  a  half  in  depth,  from  the  loss 
of  the  posterior  cul-de-sac  and  contraction  of  the  canal.  A  number  of 
folds,  radiating  in  one  direction,  gave  the  only  indication  of  the 
probable  locality  of  the  uterus,  although,  by  the  touch,  nothing  could 
be  identified  but  the  pi-essure  of  a  dense  mass  of  cicatricial  tissue, 
which  was  exquisitely  sensitive.  On  passing  the  finger  into  the  rec- 
tum, the  presence  of  the  uterus  could  not  be  recognized,  and  the 
tissues  of  the  pelvis  seemed  solidified.  A  mass  was  felt  above  the 
pubes,  which  was  supposed  to  be  the  uterus  enlarged  from  retained 
menstrual  blood.  From  long  suffering  and  the  presence  of  this  mass 
of  cicatricial  tissue  in  the  vagina,  her  nervous  system  had  been  so 
overtaxed  that  she  had  at  length  reached  a  condition  of  mind  render- 
ing her  almost  a  fit  subject  for  a  lunatic  asylum. 
15 


226  ABSENCE  OF  THE  VAGINA. 

It  would  be  out  of  place  to  discuss  this  mode  of  amputating  the 
cervix,  but  I  will  simply  state  that  for  some  fifteen  years  I  have  not 
resorted  to  it,  in  consequence  of  seeing  just  such  results  follow  my 
own  handiwork.  It  Avas  a  favorite  mode  of  treatment  both  with  Dr. 
Sims  and  myself  in  the  Woman's  Hospital  previous  to  that  time.  I 
then  possessed  the  advantage,  which  few  have  at  the  present  day, 
of  being  able  to  correct  my  errors  by  observing  the  cases  long  after- 
wards, since  they  were  then  obliged  to  return  for  relief  to  the  only 
institution  of  the  kind  in  the  country.  When  any  portion  of  the  cervix 
is  removed  by  this  method,  stenosis  is  a  very  frequent  occurrence 
within  two  years  after  the  operation.  When  a  surface  is  left  to  heal 
by  granulation,  cicatricial  tissue  must  necessarily  be  formed,  and  it 
cannot  be  denied  that  this  tissue  always  contracts,  therefore  stenosis 
must  be  a  common  result.  But,  whenever  the  vaginal  tissue  is  in- 
cluded, we  have  a  yet  more  serious  condition  to  deal  with.  As  soon 
as  the  vaginal  tissue  heals,  it  contracts  over  the  stump,  as  if  drawn 
with  a  running  string,  so  the  uterus  becomes  at  length  covered  by  two 
thicknesses  of  the  vaginal  wall.  The  occurrence  of  cellulitis,  also,  is 
not  an  uncommon  complication,  and  is  due  to  inflammation  extending 
into  the  pelvis  from  the  connective  tissue  about  the  cervix,  which 
becomes  involved  at  the  time  of  the  operation. 

I  lost  sight  of  this  case  until  April  8,  when  she  was  brought  into 
my  office  with  most  violent  contractions  of  the  uterus,  as  if  she  were 
in  the  last  stage  of  labor.  The  uterus  could  be  felt  through  the 
abdominal  wall,  contracting  with  such  force  that  I  feared  rupture 
would  take  place  and  its  contents  escape  into  the  abdominal  cavity. 
The  case  was  so  urgent  a  one  that  I  was  obliged  to  dismiss  my  office- 
patients,  and,  with  only  the  aid  of  a  nurse,  I  placed  her  under  the  efi'ect 
of  ether,  hoping  to  find  some  means  of  getting  into  the  uterus.  Failing 
to  detect  any  point  to  guide  me,  I  attempted  to  force  a  trocar  through 
this  dense  tissue  in  the  supposed  direction  of  the  uterus,  but  Avas 
unable  to  do  so.  I  then  plunged  a  sharp-pointed  bistoury  in  the  same 
direction,  and  entered  the  uterine  cavity  after  passing  through  nearly 
an  inch  of  tissue.  I  was  unable  to  judge  at  what  point  I  had  entered 
the  uterus,  but,  if  through  the  cervix,  the  canal  must  have  been  closed 
throughout.  Six  ounces  of  fluid  escaped,  and  it  continued  to  flow 
until  the  following  day.  Through  fear  of  exciting  inflammation,  I 
did  not  dare  to  enlarge  the  opening  or  to  introduce  any  substance  to 
keep  it  from  closing.  It  ay  as  impossible  to  wash  out  the  cavity,  and 
the  after-treatment  consisted  in  keeping  her  quiet  in  bed  and  under 
the  influence  of  opium.    After  ten  days  I  allowed  her  to  return  home. 

June  6.  I  found  the  opening  had  entirely  closed.  I  then  gave 
her  ether,  and,  following  the  same  course,  made  (pute  a  free  opening, 
with  no  difficulty,  except  from  hemorrhage,  Avhich  came  from  the 
vaginal' tissue  and  needed  a  tampon  for  its  control. 

Oct.  27.  She  returned,  stating  that  she  had  menstruated  seve- 
ral times,  and  without  pain,  but  that  she  had  suft'ered  very  much 
latterly,  and  had  liad  no  show  at  the  time  for  tlie  last  period.  On  the 
following  day,  with  the  assistance  of  Dr.  George  T.  Harrison  and  Dr. 


ABSENCE  OF  THE  UTERUS.  227 

Purely,  Jr.,  she  was  etherized,  and,  after  making  my  way  into  the 
cavity,  I  divided  the  tissues  laterally,  in  four  different  directions,  to 
the  fullest  extent,  without  entering  the  peritoneal  cavity.  The  wound 
was  packed  with  cotton  which  had  been  saturated  in  a  solution  of 
alum,  and  over  this  was  placed  a  pad  wet  with  glycerine. 

?A}t1i.  She  had  a  chill,  with  a  rapid  increase  of  pulse  and  elevation 
of  temperature.  The  dressing  was  all  removed,  and,  for  fear  of  blood- 
poisoning,  I  passed  a  large  double  catheter  into  the  uterus,  and  through 
this  injected  a  large  basinful  of  hot  water,  to  which  a  little  carbolic 
acid  had  been  added.  I  then  made  a  drainage  tube  from  a  portion 
of  block  tin  tubing,  about  an  inch  and  a  half  in  length,  dividing  it 
into  three  portions,  the  middle  one  being  for  the  tube,  and  I  cut 
away  from  each  end  all  but  enough  to  form  two  prongs,  or  flanges, 
half  an  inch  long,  opposite  to  each  other.  This  was  introduced,  and 
the  prongs  within  the  cavity  were  spread  apart  by  passing  a  pair  of 
scissors  through  the  tube  and  then  separating  the  blades.  The  prongs 
on  the  vaginal  end  were  turned  back,  so  that  the  tube  became  fixed 
in  the  Avound,  like  a  button  in  a  buttonhole.  She  began  to  improve 
afterwards,  and  returned  home  in  three  weeks.  After  the  next 
period,  I  introduced  a  hollow  hard-rubber  tube,  some  two  inches  long, 
slightly  curved,  and  in  appearance  not  unlike  the  instrument  used 
for  the  trachea,  with  the  exception  that  there  was  a  long  lateral  slit 
or  opening  on  each  side.  With  great  difficidty,  and  by  watching  her 
every  few  days,  I  was  able  to  keep  some  contrivance  of  the  kind  in 
the  passage  for  fourteen  months.  I  then  abandoned  the  tube,  as  it 
had  caused  her  to  menstruate  too  freely  from  the  irritation  produced 
by  its  presence  in  the  canal.  She  was  under  observation  for  a  month 
or  two  longer,  and  I  flattered  myself  that  I  had  relieved  her.  During 
the  past  winter  she  has  suffered  very  much  and,  at  length,  she  ceased 
to  menstruate  during  a  long  attack  of  cellulitis,  through  Avhich  she 
was  attended  by  Dr.  Jos.  C.  Hutchison,  of  Brooklyn.  She  was  too 
ill  to  visit  me  for  several  months,  until  recently,  when  I  made  an 
examination  and  found  her  condition  essentially  the  same  as  it  was  at 
the  time  of  my  first  examination,  over  three  years  before.  Her  future, 
in  all  probability,  is  to  be  death  from  peritonitis  or  blood-poisoning. 

Case  X. — Mrs.  St.  .J.,  aged  21,  was  admitted  to  the  "Woman's 
Hospital  Oct.  1,  1869.  At  fourteen  she  felt  pain  in  the  side  and 
back  with  headache,  and  these  pains  returned  afterwards  with  great 
regularity,  as  at  the  menstrual  period,  but  without  a  show.  After  a 
careful  examination,  I  was  unable  to  detect  any  evidence  of  the  uterus, 
but  as  she  was  a  married  woman  I  decided  to  operate  for  making  a 
vagina.  Oct.  12th,  this  was  done  without  difficulty,  by  the  method 
described,  and  I  had  already  completed  the  canal  to  the  depth  of  three 
inches,  Avhen  I  accidentally  ruptured  the  septum  just  below  the  bottom 
of  Douglas's  cul-de-sac,  and  opened  into  the  rectum.  As  the  glass 
plug  could  not  be  used  under  these  circumstances,  the  operation  was 
abandoned,  and  the  parts  were  allowed  to  close.  Jan.  27,  1870,  I 
again  operated,  and  at  the  time  of  her  discharge,  Feb.  18,  the  canal 


228  ABSENCE    OF    THE    VAGINA. 

had  healed,  and  was  four  and  a  half  inches  deep.  No  uterus  was 
found,  and  the  case  has  only  been  presented  to  show  that  accidental 
rupture  into  the  rectum  is  of  little  consequence  beyond  the  delay  it 
involves. 

In  forming  a  vagina,  it  is  essential  that  the  whole  operation  be 
completed  in  one  sitting,  and  that  the  passage  be  made  much  larger 
than  necessary,  since  it  will  contract  under  all  circumstances.  If  the 
operation  be  only  partially  performed,  and  afterwards  completed, 
contraction  will  always  take  place  at  the  dividing  line  between  the 
two  operations,  and  will  be  a  source  of  irritation  afterwards,  and  this 
band  must  always  be  overstretched  before  the  other  portion  of  the 
canal  can  be  dilated.  The  surface  lining  the  canal  is  essentially  a 
cicatricial  one,  and  will  consequently  contract  to  a  greater  or  less 
extent,  but  when  healed  over  glass  it  approaches  nearest  in  character 
to  a  mucous  membrane.  When  tissues  are  divided  by  the  knife,  the 
contraction  is  always  greater  than  when  lacerated  or  broken  up  by 
means  of  the  scissors.  If  a  passage  be  opened  by  the  knife  alone, 
the  plug  will  be  gradually  expelled  by  adhesion  of  the  surfaces,  from 
above  downward,  until  the  original  condition  is  attained.  This  will 
always  occur,  unless  some  portion  of  the  mucous  membrane  has  re- 
mained intact  at  the  upper  part  of  the  canal.  When  merely  a  section 
of  the  vagina  has  been  divided,  the  required  diameter  can  be  pre- 
served as  long  as  a  bougie  is  retained,  but  after  discontinuing  its  use, 
the  incised  tissue  will  gradually  contract  until  the  false  passage  be- 
comes obliterated,  or  reduced  to  a  mere  sinus.  Experience  teaches  us 
that  a  surface  which  has  been  lacerated  heals  Avith  less  rapidity  than 
when  divided  by  the  knife.  Consequently,  if  the  tissues  be  cicatricial 
in  character,  we  will  thus  gain  time  for  the  modifying  effect,  through 
absorption,  which  will  be  excited  by  the  pressure  of  the  dilator. 

A  common  and  undesirable  result  is  often  obtained  in  the  operation 
for  opening  a  vagina,  as  shown  in  Cases  VII.  and  IX.,  in  each  of 
which  a  constriction  was  left.  To  avoid  this,  it  is  necessary  that  the 
new  canal,  opening  into  the  portion  dilated,  should  be  as  large  in 
diameter,  if  not  larger  than  any  other  part,  since  that  which  has  been 
overstretched  will  contract  with  greater  rapidity,  thus  leaving  this 
constricted  portion  as  a  source  of  irritation  afterwards.  Whenever 
the  canal  has  been  opened  throughout  by  a  single  operation,  and  to  a 
uniform  calibre,  it  can  be  kept  open  afterwards  for  an  indefinite  period 
without  irritation,  by  the  introduction,  daily,  of  the  glass  plug,  and 
retainins  it  for  a  few  moments. 


EVACUATION  OF  MENSTRUAL  BLOOD.  229 

It  has  been  recommended  by  all  writers  that  the  retained  menstrual 
blood  shall  be  evacuated  slowly,  through  fear  that  it  may  escape  by 
the  Fallopian  tubes  into  the  abdominal  cavity.  I  regard  this  fear 
as  based  entirely  on  theoretical  views.  Dilatation  of  these  tubes 
throughout  their  length  must  necessarily  be  rare.  If  it  were  so  easy 
for  the  fluid  to  escape  when  this  condition  exists,  it  would  always 
be  driven  out  into  the  abdomen  by  uterine  contractions,  for  they 
are  frequent  long  before  a  necessity  is  recognized  for  surgical  inter- 
ference. If  it  were  known  that  they  were  dilated  and  filled  with 
fluid  at  the  time  of  the  operation,  it  would  be  to  the  safety  of  the 
woman  that  a  free  opening  should  be  made  below,  as  the  fluid  would 
naturally  flow  in  the  direction  offering  the  least  resistance.  No 
attempt  should  be  made  to  aid  the  expulsion  of  the  fluid  from  the 
uterine  cavity  by  manipulating  the  organ  through  the  abdominal 
walls.  Should  the  Fallopian  tubes  be  distended  by  fluid,  such  inter- 
ference would  be  more  likely  to  rupture  them,  or  to  force  the  blood 
into  the  abdominal  cavity,  than  would  the  uterine  contraction. 

After  the  uterine  cavity  has  been  emptied,  its  walls  will  remain 
smeared  with  this  tar-like  fluid,  which  cannot  be  gotten  rid  of  for 
several  days,  until  it  has  become  partially  decomposed  and  broken 
down  to  a  watery  consistency.  With  the  anaemic  condition  of  the 
patient,  and  the  irritable  state  of  her  whole  system,  she  is  the  more 
susceptible  to  blood-poisoning,  and  it  is  remarkable,  under  the  circum- 
stances, that  it  does  not  occur  much  more  frequently.  With  all  due 
care,  it  is  often  impossible  to  protect  the  woman  fully  from  this  danger, 
or  from  inflammation,  yet  the  risk  must  be,  beyond  question,  greatly 
lessened  by  thoroughly  washing  out  the  uterine  cavity. 

Dr.  C.  H.  F.  Routh  reports^  a  case  of  congenital  absence  of  the 
vagina,  with  retained  menstruation,  on  which  he  operated  for  opening 
a  vagina,  Jan.  7,  18T0.  The  passage  was  made  chiefly  by  aid  of  the 
finger,  and  the  fluid  was  allowed  to  escape  by  a  small  opening.  "Its 
exit  was  helped  by  an  injection  of  a  weak,  warm  watery  solution  of 
iodine."  A  large  gum-elastic  catheter  was  left  fastened  in  situ  with 
tapes.  The  same  weak  solution  of  iodine,  to  which  carbolic  acid  was 
added,  was  used  to  wash  out  the  canal  as  the  discharge  became  pro- 
fuse. Death  resulted  on  the  seventh  day.  It  was  found  at  the  post- 
mortem examination  that  a  teacupful  of  the  fluid  had  escaped  into 

'   "On  a  Remarkable  Case  of  Absence  of  Vagina,  etc."     Transactions  of  the 
Obstetrical  Society  of  London,  vol.  xii.  p.  34. 


230  ABSENCE    OF    THE    VAGINA. 

tlie  abdominal  cavity  through  an  aperture  in  the  dilated  tube,  on  the 
right  side,  which  "  was  sloughy  looking." 

In  the  progress  of  this  case,  lasting  a  week,  there  were  symptoms 
of  blood  poisoning,  but  not  such  as  would  have  been  expected  had  this 
quantity  of  fluid  remained  in  the  abominal  cavity  from  the  time  of  the 
operation.  Therefore,  in  the  absence  of  extensive  peritonitis,  I  believe 
rupture  of  the  tube  took  place  but  a  short  time  before  death.  In- 
flammation and  sloughing  of  the  tube  had  been  going  on  for  several 
days,  in  consequence  of  the  distension,  and  the  blood  poisoning  may 
have  originated  from  this  condition.  Rupture  and  escape  of  the  fluid 
into  the  abdominal  cavity  was  evidently  but  a  question  of  a  few  days, 
therefore,  a  premature  occurrence  might  have  taken  place  when  she 
"  was  rather  frightened  by  noise  in  an  upper  ward,  and  said  she  felt 
as  if  something  had  turned  completely  in  her  inside."  This  was  at 
an  alarm  of  fire,  and  it  is  reasonable  to  suppose  that  rupture  did 
occur  at  this  time,  as  shortly  after,  "  the  whole  aspect  of  the  patient 
was  indicative  of  shock  and  internal  hemorrhage,"  a  condition  which 
continued  until  her  death. 

As  the  fluid  did  not  escape  from  the  fimbriated  extremity  of  the 
tube,  when  subjected  to  compression,  it  may  be  assumed  that  the 
canal  had  been  dilated  from  the  uterus.  In  other  words,  that  the 
mouth  of  the  tube  entering  the  uterus  was  the  most  dilated  portion 
when  the  organ  was  distended.  If  this  be  true,  the  fluid  would  have 
passed  out  of  the  tube  into  the  uterus,  with  a  free  outlet  below  for  its 
escape  at  the  time  of  the  operation.  The  probabilities  are  all  in  favor 
of  the  supposition  that,  had  there  been  this  free  outlet,  the  fluid  Avould 
have  been  drawn  out  in  the  direction  of  the  current  before  it  became 
thus  imprisoned  by  the  gradual  contraction  of  the  uterus. 

Dr.  J.  M.  Richmond,  of  St.  Joseph,  Mo.,  has  reported^  the  result  of 
an  operation  for  opening  the  vagina  in  a  case  of  complete  occlusion, 
which  resulted  at  eight  years  of  age,  from  a  traumatic  injury,  similar 
to  the  one  described  in  Case  IV.  He  followed  the  mode  of  operating 
recommended  by  me  in  the  paper  to  which  I  have  already  referred. 
He  was  unable  to  find  the  uterus  at  the  first  operation,  as  I  had 
fortunately  succeeded  in  doing  in  my  case ;  but  a  similar  feature  in 
both  cases  existed  in  regard  to  the  uterus,  in  that  no  attempt  at  de- 
velopment was  made  until  the  vagina  had  been  completed.  Dr.  Rich- 
mond's case  was  one  of  a  married  Avoman,  aged  21,  in  whom,  after  a 

'  St.  Louis  Medical  and  Surgical  Journal,  Jan.  1877. 


OPENING  THE  VAGINA.  231 

careful  examination  by  the  rectum,  no  evidence  of  the  existence  of  the 
uterus  couhl  be  detected.  July  31, 1871,  a  vagina  was  opened  to  the 
depth  of  three  inches,  and,  after  it  had  healed,  on  Sept.  G,  the  canal 
•was  extended  to  nearly  five  inches  without  finding  the  uterus.  The 
case  Avas  treated  by  injections,  as  I  had  recommended,  and  the 
parts,  as  in  my  operation,  were  healed  over  a  glass  plug.  Three 
months  after  the  last  operation  there  was  a  slight  show,  but  its  source 
was  not  detected.  In  Feb.  1872  the  menstrual  blood  was  discovered 
oozing  through  a  small  opening ;  this  was  enlarged,  and  the  os  uteri 
found,  into  which  a  probe  passed  to  the  depth  of  less  than  two  inches. 
The  uterus  afterwards  developed,  she  continued  to  menstruate  regu- 
larly, and  the  vagina  remained  open.  An  additional  value  of  the 
record  is  the  satisfactory  report  of  the  case  made  five  years  after  the 
operation. 

Dr.  Routh,  in  his  remarks  before  the  Obstetrical  Society  on  the 
report  of  his  case,  states  :  "  Among  the  few  cases  of  absence  of  the 
vagina  recorded,  /  do  not  find  any  in  wJiich  the  case  exactly  resembled 
this,  and  in  which  the  vagina  was  made,  and  the  uterus  punctured 
at  the  same  time,  sponge  tents  having  been  used  after  incisions  made, 
and  the  progress  of  the  operation  extended  over  several  days." 

This,  however,  was  nearly  four  years  after  I  had  placed  on  record 
my  method  of  operating ;  just  six  years  after  the  operation  had  been 
witnessed  by  the  members  of  the  American  Medical  Association ;  and 
about  seven  years  after  my  first  case. 

Amussat,  in  the  report  of  his  case  given  several  years  after  the 
operation,  throAvs  out  the  hint  that  in  a  similar  instance  he  would 
favor  the  completion  of  the  canal  at  one  operation,  but  he  never  put 
the  suggestion  into  practice.  All  operators  subsequent  to  Amussat 
followed  his  teaching  in  opening  the  vagina  by  several  distinct  opera- 
tions, and  in  the  gradual  evacuation  of  the  retained  menstrual  fluid  by 
a  small  opening.  Although  he  broke  down  the  tissues  with  his  finger, 
fearing  to  use  the  knife,  it  was  done  chiefly  to  form  a  bed  for  inser- 
tion of  the  sponge,  and  by  a  method  entirely  different  from  the  one 
described  by  me. 

I  may,  therefore,  claim  to  have  been  the  first  operator  on  record 
who  completed  the  opening  of  the  canal  at  a  single  operation  ;  to  have 
separated  the  tissues  by  freely  sweeping  the  finger  from  one  side  of 
the  pelvis  to  the  other ;  to  have  given  free  exit  to  the  retained  fluid ; 
and  then  to  have  washed  out  the  uterine  cavity  with  warm  water, 
that  blood-poisoning  might  not  result. 


232  ABSENCE    OF    THE    VAGINA. 

To  complete  the  canal  at  one  operation  is  based  on  sound  surgical 
principles,  for  thus  the  danger  from  inflammation  becomes  greatly 
lessened.  The  entrance  from  the  new  passage  into  the  expanded  por- 
tion about  the  cervix,  should  always  be  made  larger  than  any  other 
part  of  the  vagina,  for  otherwise,  there  will  remain  a  constriction  at 
this  point.  The  formation  of  such  bands  must  be  prevented,  since 
the  calibre  of  the  canal  can  never  be  said  to  be  greater  than  its  most 
constricted  part,  and  the  presence  of  a  band  always  renders  the 
patient  more  liable  to  the  occurrence  of  cellulitis,  from  the  irritation 
produced  by  the  introduction  of  the  dilator,  or  plug.  Unless  a  dilator 
be  frequently  used,  the  new  canal  will  always  contract  to  some  extent, 
and  unless  it  be  soft,  and  of  a  uniform  calibre  throughout,  it  will  be 
impossible  to  keep  it  open. 

I  have  pointed  out  the  advantages  of  allowing  the  menstrual  fluid 
to  have  a  free  exit,  and  there  can  be  no  objections  advanced  to  the 
procedure  except  on  theoretical  grounds.  Having  shown  that  there 
is  no  danger  of  forcing  the  fluid  through  the  tubes  into  the  abdominal 
cavity,  the  possibility  of  shock  to  the  patient  in  consequence  of  the 
too  rapid  escape  of  the  fluid  from  the  uterine  cavity  may  be  next 
considered.  From  the  fresh  opening,  it  would  be  impossible,  on 
account  of  the  tenacious  character  of  the  fluid,  to  empty  the  uterus 
so  rapidly  as  to  produce  any  shock.  If  such  a  result  were  likely  to 
follow  the  rapid  evacuation  of  fluid  from  the  uterus,  it  should  at  least 
sometimes  occur  from  the  sudden  escape  of  the  liquor  amnii. 

The  glass  plug  was  introduced  by  Dr.  Sims,  to  be  used  after  having 
divided  cicatricial  bands  in  the  vagina,  that,  by  pressure,  absorption 
might  take  place,  and  the  parts  be  softened  down,  preparatory  to 
closing  a  vesico-  or  recto-vaginal  fistula.  I  was  the  first  to  employ 
this  instrument  in  the  after-treatment  of  the  operation  for  forming  an 
artificial  vagina. 

After  a  thorough  injection  of  warm  water  has  been  given,  and  a 
glass  plug  of  a  proper  size  introduced,  all  the  air  and  fluid  in  the 
vagina  will  have  been  displaced,  or  pressed  out.  The  parts  are  thus 
shut  out  from  the  action  of  the  air,  and  the  instrument  is  retained  in 
place,  by  atmospheric  pressure,  as  long  as  the  woman  remains  quiet. 
The  instrument  is  cool,  clean,  and  unirritating  ;  it  keeps  up  steady 
pressure  on  the  parts,  and,  consequently,  prevents  undue  congestion. 
But,  above  all,  it  possesses  two  great  advantages,  but  only  when 
made  of  glass,  viz.,  that  of  being  innocuous  and  transparent,  so  that 
it  inflicts  no  injury,  and  allows  of  the  surfaces  being  seen  at  all  times, 
as  through  a  speculum,  without  its  removal. 


OPENING    THE    VAGINA.  233 

I  regard  the  washing  out  of  the  uterine  cavity  as  the  most  important 
precaution  against  Wood  jjoisoning,  and  next  in  importance  to  this  I 
place  the  use  of  this  instrument,  to  which  I  attribute  a  success  which 
has  been  equally  great  with  all  who  have  employed  the  same  method. 

To  fill  a  cavity,  made  through  loose  cellular  tissue,  as  has  been  the 
general  practice,  with  porous  substances,  as  sponge,  lint,  etc.,  which 
must  retain  and  keep  the  parts  bathed  in  the  decomposed  discharges, 
establishes  a  condition  so  favorable  to  blood-poisoning  and  inflammation 
that  it  would  be  remarkable  if  any  case  should  escape. 


234  PELVIC    HEMATOCELE. 


CHAPTER    XII. 

PELVIC  HEMATOCELE. 

Definition — History — Applied  terms — Source  of  tlie  blood — Freqiiency — Symptoms 
— Varieties — Differential  diagnosis — Treatment. 

Definition. — An  accidental  collection  of  blood  in  the  pelvis,  either 
in  the  peritoneal  cavity,  or  outside  of  the  peritoneum,  within  the  con- 
nective tissue  of  the  pelvis. 

A  hematocele  is  a  symptom  and  not  a  disease,  simply  a  result 
from  one  of  many  different  causes,  any  or  all  of  which  may  give  rise 
to  it. 

History. — The  greatest  difference  of  opinion  has  been  maintained 
from  the  beginning,  and  almost  to  the  present  time,  in  regard  to  nearly 
every  essential  featvire  of  this  condition.  The  literature  on  the  sub- 
ject has  become  voluminous.  The  contributions  from  the  French 
writers  are  the  most  extensive  ;  in  Germany  and  Great  Britain  almost 
as  much  has  been  written ;  while  the  subject  has  received  compara- 
tively but  little  attention  in  this  country. 

Whatever  may  have  been  the  knowledge  of  the  older  writers  on 
this  subject  is  now  of  little  practical  value  to  us,  since  they  have  trans- 
mitted their  views  in  terms  too  vague. 

Recamier  described,  in  1831,  a  pelvic  tumor  filled  with  blood,  which 
he  cut  into,  mistaking  it  for  an  abscess.  Other  writers  in  Paris  shortly 
after  recorded  similar  cases,  but  to  Nelaton^  I  think  must  be  credited 
the  first  accurate  description  given  of  the  pathology  of  the  lesion. 
These  claims  of  priority  are  challenged  by  Bernutz,  and  are  granted 
to  him  by  many  writers.  His  first  contribution  to  the  subject  was 
given  in  the  ArcJiives  Generates  de  Medecine,  1848  and  1849. 
Afterwards  he  presented  his  views  in  a  more  extended  form,^  which 
was  translated  and  edited  by  Dr.  Alfred  Meadows,  in  1866,  for  the 
New  Sydenham  Society,  London.     From  this  work  I  quote i^  "To 

1  Gazette  des  Hopitaux,  1851  and  1852. 

"  Clinique  Medicale  sur  les  Maladies  des  Femmes,  par  MM.  Bernutz  et  Goupil, 
Paris,  1860. 

3  Vol.  i.,  part  2,  p.  159,  note. 


HISTORY    AND    LITERATURE.  235 

Ruysch  (1691)  undoubtedly  belongs  the  honor  of  having  first  men- 
tioned the  escape  of  menstrual  blood  into  the  peritoneum,"  "To  M. 
H.  Bourdon  (184:1)  belongs  the  credit  of  having  first  described  the 
physical  signs  of  those  blood  tumors  now  called  hematoceles,  Avhich 
he  thought  were  situated  in  the  peri-uterine  cellular  tissue,  but  whose 
relation  to  menstrual  irregularity  he  entirely  ignored."  "M.  Velpeau 
(1813)  had  the  honor  of  first  diagnosing  during  life  one  of  these 
blood  tumors,  without  having  recourse  to  an  exploratory  incision, 
though  he  did  not  recognize  its  exact  situation  nor  its  relation  to 
menstrual  disturbance."  "I  may,  perhaps,  be  allowed  to  state  that: 
1st.  No  one  can  claim  to  have  preceded  me  in  pointing  out  the  rela- 
tion which  exists  between  these  blood  effusions,  now  called  hemato- 
celes, and  disturbances  of  menstruation,"  etc.  "  2d.  That  hardly  any 
addition  has  been  made  to  the  anatomico-pathological  description  of 
hematoceles  which  I  first  sketched  out." 

Dr.  Tilt,  a  student  of  Recamier,  Avas  the  first  English  writer  to 
describe  the  condition,  in  a  paper  read  before  the  Medical  Society 
of  London,^  and  in  the  second  edition  of  his  work.  Dr.  West  also 
describes  the  lesion  in  his  work,  which  was  published  about  the  same 
time.  Professor  Simpson  recognized  the  accident  in  1854,  an  account 
of  the  case  being  published  in  the  Medical  Times  and  Grazette,  1859, 
and  subsequently  in  his  works.  A  knowledge  of  hematocele  became 
more  general  after  the  clinical  work  of  Bernutz  and  Goupil  was 
published.  One  of  the  most  complete  cases  on  record  was  presented 
by  Dr.  Henry  Madge  in  a  paper"  On  Uterine  Hematocele,"  published 
in  the  Transactions  of  the  London  Obstetrical  Society,  vol.  iii.,  1861. 
Dr.  Matthews  Duncan,  of  Edinburgh,  contributed  a  valuable  paper  on 
the  subject  to  the  Edinburgh  Medical  Journal,  1861.  An  extended 
article  "  On  Pelvic  Hematocele,  with  special  reference  to  its  Diagnosis 
and  Treatment,"  by  Dr.  Alfred  Meadows,  was  published  in  the  Trans- 
actions of  the  London  Obstetrical  Society,  vol.  xiii.,  1871.  The 
works  of  Tilt,  Bennett,  West,  Simpson,  Churchill,  McClintock,  Hewitt, 
Barnes,  and  others,  all  contain  additional  material  gathered  from 
personal  observation. 

In  Germany,  Prof.  Braun,  of  Vienna,  in  1861,  wrote  an  extended 
article  on  the  subject  of  hematocele,  and  Virchow,  Olshausen,  Fritsch, 
Schroeder,  Beigle,  Klebs,  and  others  have  made  valuable  contributions. 

The  most  complete  treatises  in  the  French  language  are  by  Ber- 

'  Publislied  in  the  London  Lancet,  1853. 


236  PELVIC    HEMATOCELE. 

riutz  and  Voisin,  in  1860;  in  the  German,  by  Dr.  C.  Scliroeder  ;^ 
and  in  the  English  that  by  Dr.  Tuckwell,  Oxford,  1864. 

In  this  country,  as  I  have  stated,  there  seems  to  be  but  little 
literature  on  the  subject  beyond  the  reports  of  isolated  cases  scattered 
through  the  joumials.  Prof.  G.  S.  Bedford,  of  New  York,  in  1855, 
recognized  the  existence  of  a  hematocele  in  a  case  presented  at  his 
clinic.  The  tumor  was  tapped,  and  a  description  of  the  case  is  given 
in  his  work  on  the  diseases  of  women.  Dr.  John  Byrne,  of  Brooklyn, 
in  1862,  read  a  paper  on  hematocele  before  the  New  York  Academy 
of  Medicine,  which,  after  being  extended,  was  published  by  Wm. 
Wood,  New  York,  1862.  This  monograph  contains  the  report  of 
several  cases,  and  was  a  full  digest  up  to  that  time,  and  was,  I  believe, 
the  first  paper  printed  on  the  subject  in  this  country.  The  American 
Journ.  of  Obstet.,  New  York,  August,  1873,  contains  "  Remarks  upon 
the  Diagnosis  of  Pelvic  Hematocele,"  by  Dr.  Lee,^  who  reports  some 
cases  under  his  observation,  and  is  valuable  for  its  bearing  on  the 
differential  diagnosis.  In  the  Virginia  (Richmond)  Medical  Monthly 
for  October  and  November,  1875,  will  be  found  an  extensive  article 
on'  " Retro-viterine  Hematocele — a  Gynaecological  Study,"  by  Dr. 
Harrison.^  Some  cases  are  given,  and  the  literature  on  the  subject 
is  very  complete.  The  paper  is  written  to  show  the  chief  source  of 
hemorrhage  in  cases  of  hematocele,  and  will  be  again  referred  to. 

Applied  Termis. — Bernutz  prefers  the  term  peri-uterine  hematocele, 
as  expressing  the  fact  that  the  blood  may  accumulate  at  any  point 
about  the  uterus.  He  was  of  the  opinion  "that  the  bloody  tumor 
which  is  left  as  the  remains  of  a  hematocele  has  no  right  to  be 
regarded  as  a  specific  disease,  apart  from  that  which  caused  it,"  "the 
hemorrhage  itself  being  regarded  merely  as  a  symptomatic  expression 
of  these  morbid  conditions,"  N^laton  termed  the  condition  retro- 
uterine hematocele,  since  he  considered  this  to  be  the  only  locality 
in  which  it  is  found.  Voisin  uses  the  same  term,  and,  with  Bernutz, 
held  that  a  true  hematocele  could  only  consist  of  an  eflFusion  within 
the  peritoneal  cavity.  Simpson,  on  the  contrary,  considered  a  hema- 
tocele to  be  usually  formed  by  hemorrhage  taking  place  outside  of  the 
peritoneal  sac ;  while  Bernutz  designates  such  a  blood  tumor  in  the 

'  Kritisclie  Untersuchungen  fiber  die  Diagnose  dor  nsematocelo  Retro-iiterina, 
u.  s.  w.,  Bonn,  1866. 

2  Charles  C.  Leo,  M.D.,  Assistant  Surgeon  to  tlie  Woman's  Hospital  of  the 
State  of  New  York, 

8  George  T.  Harrison,  M.D,,  Assistant  Surgeon  to  the  Woman's  Hospital  of  tho 
State  of  New  York, 


SOURCE    OP    TJIE    BLOOD.  237 

cellular  tissue  as  a  pelvic  hematoma  or  thrombus.  These  views  arc 
held  by  jMeadows  and  others,  with  the  additional  distinction  that,  as 
a  rule,  the  hematoma  is  connected  with  the  puerperal  state  or  is  the 
result  of  an  injury. 

Source  of  the  Hemorrhage. — Bernutz  regarded  the  source  of  blood 
as  in  the  uterus,  and  that  it  was  simply  the  retained  menstrual  flow, 
which  regurgitated  through  the  Fallopian  tubes.  This  view  seems  to 
merit  scarcely  more  than  a  passing  remark.  It  is  now  well  known  that 
the  contents  of  a  distended  uterus  never  pass  into  the  peritoneal  cavity, 
unless  by  rupture  of  the  organ  itself  or  of  the  uterine  portion  of  the 
tube  which  may  have  become  dilated.  Trousseau  held  the  same  view 
as  to  this  being  a  source,  but,  in  addition,  that  by  exhalation  the 
hemorrhage  might  take  place  from  the  mucous  membrane  of  the  tube 
itself.  This  might  possibly  occur,  under  certain  circumstances,  from 
that  portion  near  the  fimbriated  extremity.  Nelaton  conceived  that 
the  origin  of  the  hemorrhage,  was  from  a  rupture  of  a  Graafian  follicle, 
the  blood  naturally  gravitating  from  the  surface  of  the  ovary  to 
the  bottom  of  Douglas's  cul-de-sac,  the  most  dependent  point.  Dr. 
Madge,  in  support  of  this  view,  refers  to  the  then  well-established 
belief  that  the  firabrise  of  the  Fallopian  tubes  continued  to  grasp  the 
ovary  during  the  menstrual  period,  so  that  not  only  the  ovules  but 
all  the  blood  and  secretions  from  the  ovaries  and  tubes  passed  into 
the  uterine  cavity  at  the  same  time.  These  views  were  advanced  by 
Rouget,  and  supported  by  Gaillard,  who  even  believed  that  this  was 
the  chief  source  of  the  menstrual  blood.  Dr.  Tyler  Smith,  in  the  dis- 
cussion on  Dr.  Madge's  paper,  considered  the  blood  of  a  hematocele 
"  to  be  essentially  a  form  of  ovarian  or  Fallopian  menstruation,  vica- 
rious in  character."  Unless  under  some  unusual  condition,  the  blood 
lost  upon  the  escape  of  an  ovum  must  be  too  small  in  quantity,  and, 
from  the  frequency  with  which  the  fimbriae  are  found  bound  down 
by  adhesions  after  death,  hematocele  would  be  of  far  more  frequent 
occurrence  if  it  were  true  that  the  blood  passed  in  this  manner. 

A  number  of  cases  have  been  placed  on  record  where  the  hemato- 
cele has  been  formed  in  the  peritoneal  cavity  by  the  rupture  of  a  dis- 
tended ovary,  from  hemorrhage  taking  place  within  its  own  stroma, 
and  this  accident  has  been  termed  ovarian  apoplexy.  Bichat,  in  his 
Surgical  Anatomy,  and  Devalz,  in  a  treatise  on  "  Utero-ovarian  Varico- 
cele" call  attention  to  the  extravasation  of  blood  from  a  rupture  of 
the  utero-ovarian  vascular  plexus  forming  a  hematocele.  After  re- 
peated pregnancies,  or  from  any  cause  where  the  venous  circulation 
has  been  much  obstructed,  the  vessels  become  varicose.     A  change 


238  PELVIC    HExMATOOELE. 

has  then  been  brought  about  in  the  coats  of  these  vessels,  and  being 
without  valves  their  power  of  resistance  is  greatly  lessened.  Under 
these  circumstances,  and  with  a  condition  so  common,  it  is  a  matter 
of  surprise  that  the  accident  does  not  more  frequently  occur.  In 
fact,  a  glance  at  Savage's  plates,  showing  the  venous  circulation  about 
the  uterus,  should  convince  any  one  that  rupture  of  these  vessels 
must  be  one  of  the  most  frequent  causes  of  extravasation  of  blood 
into  the  cellular  tissue,  and  secondarily  into  the  peritoneal  cavity. 
This  rupture  may  occur — 

1st.  From  the  mass  of  vessels  known  as  the  bulb  of  the  ovary,  and 
then  it  would  pass  into  the  peritoneal  cavity. 

2d.  From  the  pampiniform  plexus  and  network  of  vessels  under  the 
tubes  and  between  the  folds  of  the  broad  ligament.  The  blood  may 
then  be  either  extravasated  into  the  cellular  tissue,  or,  by  rupture 
through  the  sides  of  the  ligament,  pass  into  the  peritoneal  cavity. 

3d.  From  about  the  vaginal  junction,  at  the  bottom  of  Douglas's 
cul-de-sac,  or  at  some  point  in  front  of  the  uterus,  but  outside  of  the 
peritoneal  sac,  so  that  the  infiltration  would  pass  into  the  connective 
tissue  of  the  pelvis. 

Eupture  of  one  of  these  vessels  may  readily  occur  about  the  time 
of  the  menstrual  flow,  during  childbirth,  or  from  a  miscarriage.  He- 
matocele frequently  results  from  excessive  sexual  intercourse,  from 
some  prolonged  exertion,  from  direct  violence,  and  even,  it  is  claimed, 
from  sudden  mental  shock.  I  have  known  the  accident  to  occur,  but 
as  an  exception  to  the  rule,  without  any  reference  to  the  time  of  either 
menstruation  or  pregnancy.  Rupture  of  the  Fallopian  tube,  from 
tubal  pregnancy,  or  of  the  sac  in  extra-uterine  abdominal  pregnancy, 
as  well  as  of  the  uterus  itself  during  the  progress  of  labor,  almost 
always  causes  serious  hemorrhage  into  the  peritoneal  cavity.  Some 
observers  have  attributed  hemorrhage  into  the  peritoneal  sac  to  the 
cachectic  condition  accompanying  ansemia,  chlorosis,  purpura  hemor- 
rhagica, and  some  of  the  eruptive  fevers. 

Virchow  has  pointed  out  a  common  source  of  hemorrhage  from  the 
new  capillary  vessels  found  in  the  false  membrane,  or  other  products 
of  a  local  peritonitis.  This  takes  place  just  as  a  clot  is  formed  on 
the  dura  mater  between  different  layers  of  exudation  or  false  mem- 
brane. Accumulations  in  the  peritoneal  cavity  gravitate  into  Doug- 
las's cul-de-sac,  and  become  there  encysted,  if  inflammation  should  be 
excited  ;  or  the  blood  may  remain  free,  forming  only  a  pool  in  the 
most  dependent  portion,  according  to  the  rapidity  with  which  it  has 
escaped. 


FREQUENCY.  239 

Hematocele  occurs,  as  a  rule,  ahout  midway  in  the  menstrual  life, 
at  a  time  when  the  organs  of  generation  are  most  active.  Yet  cases 
have  been  reported  where  the  accident  has  taken  place  several  years 
after  the  normal  cessation  of  menstruation. 

Hematocele  is  most  common  among  those  women  who  have  borne 
a  number  of  children  in  quick  succession,  yet  it  is  not  an  uncommon 
accident  with  the  sterile,  while  it  is  a  rare  occurrence  among  the  un- 
married unless  as  a  result  of  violence. 

We  find  on  no  other  point  does  there  exist  a  greater  difference  of 
opinion  than  as  to  the  frequency  of  this  accident.  I  think  the  varied 
experience  has  been  due  to  different  classes  of  patients,  and  the  dif- 
ferent circumstances  under  which  they  were  treated,  i.  e.  whether  at 
home  or  in  hospital.  It  is  a  comparatively  rare  aflfection  among  the 
wealthy  and  better  classes,  except  in  connection  with  the  puerperal 
state.  In  all  forms  the  lesion  is  most  common  among  the  poor  and 
overworked.  Again,  physicians  visiting  at  the  patients'  homes  will 
see  a  much  larger  proportion  of  cases  than  those  whose  practice  is 
confined  chiefly  to  the  office  or  to  the  wards  of  a  hospital.  In  twenty- 
five  years  there  have  been  but  four  cases  of  hematocele  treated  in  the 
Woman's  Hospital,  and  in  sixteen  years  I  have  had  but  three  in  my 
private  hospital.  On  the  other  hand,  during  the  same  time  I  have 
been  called  by  physicians  in  general  practice  to  see  a  number  of  cases 
in  consultation,  or  to  determine  the  character  of  the  lesion.  The 
explanation  is  evident,  the  onset  of  the  disease  is  generally  too  sudden 
and  violent  in  character  to  admit  of  removal  to  a  hospital.  Some 
writers  have  considered  that  women  residing  in  one  locality  were  more 
liable  to  this  accident  than  those  living  in  some  other  district. 

If  we  limit  the  acceptation  of  the  term  Hematocele  to  an  accu- 
mulation of  blood  confined  to  the  peritoneal  cavity,  the  accident  is 
comparatively  a  rare  one.  But  if  it  be  held  to  embrace  all  blood 
accumulations  in  the  pelvis,  the  occurrence  is  certainly  a  far  more 
common  one  than  the  profession  at  large  have  any  conception  of.  The 
occurrence  of  cellulitis,  which  is  ofien  supposed  to  be  the  primary 
difficulty,  is  frequently  excited,  I  am  satisfied,  by  some  unappreciated 
and  insignificant  loss  of  blood  from  the  rupture  of  a  small  bloodvessel. 
Rupture  into  the  connective  tissue  must  be  a  frequent  occurrence,  and 
while  this  may  account  for  many  of  the  sudden  attacks  of  cellulitis,  it 
as  often  takes  place  without  producing  any  noted  disturbance.  We 
are  obliged  to  acknowledge  our  ignorance  of  the  law  determining  the 
certain  degree  of  immunity  which  does  exist.  Under  ordinary  cir- 
cumstances, the  extravasation  of  a  small  quantity  of  blood  should 


240  PELYIC    HEMATOCELE. 

produce  but  little  or  no  irritation,  and  I  have  detected,  by  accident, 
in  one  instance,  quite  an  accumulation  of  blood  going  on  in  the  peri- 
toneal cavity  vrithout  the  patient  suflfering  any  discomfort.  Yet  fre- 
quently the  shock  to  the  nervous  system  will  be  profoundly  expressed 
from  the  first  escape  of  blood,  and  without  bearing  any  relation  to 
the  quantity,  unless  it  be  excessive.  Again,  the  blood  may  escape 
into  either  the  peritoneal  sac  or  into  the  cellular  tissue,  when,  after  a 
certain  amount  of  shock,  reaction  may  take  place  promptly,  and  the 
mass  be  rapidly  absorbed  without  having  excited  any  inflammation. 
Yet  symptoms  of  cellulitis  or  peiitonitis  will  be  as  often  manifested 
from  the  slightest  escape  of  blood,  and  without  there  being  any  close 
relation  to  the  extent  of  effusion. 

Symptoms. — An  attack  of  hematocele  may  be  preceded  by  pains 
about  the  pelvis,  and  a  feeling  of  discomfort  from  an  increased  quantity 
of  blood  flowing  to  the  parts,  but  the  bearing  of  these  symptoms 
would  be  likely  overlooked  or  attributed  to  other  causes.  Menstrua- 
tion, if  existing  at  the  time,  may  suddenly  cease,  or  may  have  been 
unduly  prolonged  before  the  attack  without  any  apparent  reason. 
But  a  sudden  attack,  without  any  premonitory  symptom,  is  the  rule, 
and,  while  the  symptoms  are  often  less  urgent  than  would  seem  justi- 
fied by  the  extent  of  hemorrhage,  the  degree  of  suffering  will  be  a 
better  indication  of  the  prognosis.  A  sudden  and  excruciating  pain 
over  the  abdomen,  but  more  intense  about  the  region  of  the  pelvis, 
may  be  given  as  the  first  symptom  of  hematocele.  The  pain  will  be 
accompanied  by  nausea  or  vomiting  of  bile,  and  with  all  the  symptoms 
of  collapse  from  shock  to  the  nervous  system,  or  from  loss  of  blood. 
The  extremities  may  be  cold,  the  skin  bathed  with  sweat,  the  features 
pinched  in  appearance,  and  the  pulse  rapid  and  weak,  or  impercep- 
tible at  the  wrist.  There  can  be  no  mistaking  the  gravity  of  the 
attack  if  a  serious  one,  for  it  will  be  as  marked  as  the  collapse  of 
cholera.  The  pain  is  beyond  every  other  symptom  the  most  charac- 
teristic, and  is  as  excruciating  as  if  the  tissues  were  being  torn  apart 
with  violence.  In  addition,  there  may  be  great  irritability  of  the 
bladder,  and  tenesmus,  excited  by  pressure  of  the  mass. 

These  symptoms  may  gradually  subside  in  intensity,  and  convales- 
cence set  in,  or  an  aggravation  may  take  place  in  a  short  time  from 
fresh  hemorrhage  attended  with  a  more  profound  degree  of  collapse 
than  before,  or  even  death  may  soon  result.  In  other  instances  the  first 
efiusion  of  blood  may  have  been  slight,  or  may  not  even  have  been 
recognized  until  an  attack  of  cellulitis  comes  on.  This  latter  condi- 
tion may  then  become  complicated  by  additional  hemorrhage,  forming 


PHYSICAL    SIGNS.  241 

a  hematocele  within  the  closed  space  formed  by  the  recent  attack  of 
inflammation.  In  such  a  case,  with  the  fluid  confined,  the  sufferinf' 
is  far  more  acute  than  it  would  be  were  the  blood  free  within  the 
cavity. 

AVhen  the  finger  is  introduced  into  the  vagina,  a  smooth,  round,  and 
boggy  mass,  with  or  without  fluctuation,  is  generally  felt  in  the  poste- 
rior cul-de-sac,  which,  in  proportion  to  its  size,  Avill  lift  the  uterus 
upward  and  forward  towards  the  pubes.  A  distinct  mass  is,  however, 
rarely  felt,  and  a  displacement  does  not  occur  except  when  the  fluid  is 
confined  to  a  limited  space,  or  Avhen  extravasated  into  the  cellular 
tissue  beneath  Douglas's  cul-de-sac.  When  the  blood  is  poured  out 
rapidly  into  the  peritoneal  cavity,  it  will  naturally  gravitate  into 
Douglas's  pouch.  But  under  other  circumstances  a  clot  may  form 
about  the  seat  of  rupture,  so  that  nothing  can  be  detected  in  the 
cul-de-sac  for  an  indefinite  time  after  the  occurrence  of  the  accident. 
If  peritonitis  has  not  occurred,  and  the  blood  is  thrown  out  rapidly, 
it  will  accumulate,  as  any  liquid  would  do,  and  fill  up  all  the  space 
about  the  uterus,  without  displacing  the  organ.  But  cases  are  fre- 
quently met  with  where  it  would  be  exceedingly  difficult  to  determine 
the  exact  locality  of  the  hematocele,  as  to  its  being  within  or  without 
the  peritoneal  cavity.  But  with  extreme  cases  the  diagnosis  may 
be  readily  formed.  Thus  an  accumulation  in  the  cellular  tissue 
of  the  pelvis  cannot  lift  the  peritoneum  to  any  great  extent  without 
rupture.  But  after  the  blood  escapes  into  the  peritoneal  cavity,  it 
will  be  impossible  to  distinguish  the  condition  from  an  original  accu- 
mulation. When  a  hematocele  is  formed  within  the  peritoneal  cavity 
it  may  slowly  enlarge,  and  extend  out  of  the  pelvis  on  the  side  of 
rupture,  to  above  the  line  of  the  umbilicus,  although  it  may  have 
had  its  beginning  in  a  rupture  in  the  cellular  tissue.  But,  on  the 
other  hand,  if  the  mass  is  felt  extending  low  in  the  pelvis,  the  pro- 
bability is  far  greater  that  the  effusion  is  confined  to  the  cellular 
tissue.  If  simply  poured  out  into  the  peritoneal  cavity,  the  blood 
cannot  escape  ;  while  if  it  were  circumscribed  by  inflammation,  such  a 
barrier  would  be  ruptured  easier  than  the  blood  could  be  extravasated 
from  the  cavity  into  the  connective  tissue. 

As  the  case  adv^ances  the  tenderness  on  pressure  will  become  marked 
throughout  the  vagina  as  well  as  in  the  abdomen  which  is  usually 
tympanitic.  The  patient  may  be  exceedingly  restless,  but  so  long  as 
she  can  remain  in  any  one  position  it  will  be  with  the  lower  limbs 
flexed  on  the  abdomen.  When  the  accumulation  becomes  sufficiently 
large,  the  rectum  may  be  so  compressed  as  to  render  it  almost  impos- 
16 


242  PELVIC    HEMATOCELE. 

sible  to  evacuate  the  bowels,  and  the  introduction  of  the  catheter  may- 
be necessary  to  relieve  the  badder. 

The  most  extensive  accumulation  of  blood  may  suddenly  find  an 
exit  by  rupture  into  the  rectum,  with  recovery,  or,  if  encysted,  the 
rupture  may  be  into  the  peritoneal  cavity,  with  almost  immediate 
death  from  sliock.  If  neither  rupture  occurs  nor  absorption  of  the 
blood  takes  place,  rigors  come  on  and  are  followed  by  an  elevation  in 
the  temperature,  to  result  in  a  pelvic  abscess,  blood-poisoning,  or  death 
from  exhaustion. 

By  studying  the  history  of  several  type  cases  of  hematocele,  the 
reader  will  be  better  able  to  appreciate  not  only  the  location  of  the 
hemorrhage,  but  also  the  symptoms  which  usually  accompany  the 
different  forms  of  the  lesion. 

Case  XI. — Mrs.  W.,  aged  thirty-two  years,  of  Stamford,  Conn., 
came  under  my  care  in  Oct.  1864.  She  had  given  birth  to  five 
children  in  rapid  succession,  and  had  been  a  confirmed  invalid  since 
the  birth  of  her  last  child,  which  was  nearly  two  years  previous  to  con- 
sulting me.  The  uterus  was  found  very  much  enlarged  and  anteverted, 
while  at  the  same  time  it  sagged  quite  low  in  the  pelvis.  The  perineum 
had  been  lacerated,  and  the  vagina  was  relaxed,  and  there  was  a  partial 
cystocele.  A  number  of  hemorrhoids  were  discovered,  but  the  condition 
of  the  rectum  was  considered  the  most  urgent  feature  in  her  case.  She 
had  been  unable  to  stand  beyond  a  few  moments  at  a  time  since  the 
birth  of  her  last  child  without  exciting  nausea  and  tenesmus,  and  a 
feeling  of  great  fulness  about  the  pelvis,  but  Avhile  in  bed  she  was 
comfortable.  So  far  as  I  had  any  means  of  judging,  her  complaints 
were  out  of  all  proportion  to  the  local  disease,  and  I  charged  her  with 
having  contracted  the  habits  of  an  invalid.  This  statement  mortified 
her  exceedingly,  and  she  expressed  a  determination  to  carry  out  every 
direction.  Without  giving  her  time  for  reflection  I  called  two  nurses 
to  get  some  clothing  on  her,  and  directed  them  to  support  her  on  each 
side,  as  she  was  being  walked  back  and  forth  in  her  room.  In  a  few 
seconds  she  complained  of  a  feeling  in  the  pelvis  as  if  she  would 
burst,  and  of  being  nauseated.  I  persisted,  however,  that  she  should 
continue  the  walk,  as  the  only  means  by  which  she  could  regain  the 
use  of  her  lower  limbs,  but  she  soon  became  deadly  pale,  vomited, 
and  fainted.  She  was  then  put  to  bed,  and  I  was  more  puzzled 
than  before  as  to  her  condition. 

After  some  preparatory  treatment,  I  operated  for  the  removal  of 
the  hemorrhoids,  with  a  good  result,  and  then  began  to  make  applica- 
tions of  iodine  within  the  uterus,  with  the  hope  of  reducing  its  size. 

On  one  occasion,  when  within  a  few  days  of  the  time  for  her  men- 
strual period,  I  had  more  difficulty  than  usual  in  drawing,  with  a 
tenaculum,  the  cervix  forward  enough  to  admit  of  the  introduction 
of  the  application  within  the  uterine  canal,  and  in  doing  so  I  gave 
her  great  pain.     It  had  been  my  custom  to  leave  this  case  until  the 


RETRO-UTERINE    HEMATOCELE. 


243 


last  as  she  required  so  much  time  and  aid  from  the  nurse,  and  on  tliis 
day  I  left  the  liouse  without  indicating  my  route.  At  the  end  of  an  hour 
I  returned  by  the  merest  accident,  and  found  her  almost  in  a  collapse, 
suffering  from  excruciating  agony,  and  bearing  down  as  if  in  the  last 
stages  of  labor.  She  had  complained  of  great  pain  from  the  moment 
of  my  examination,  but  until  she  began  to  vomit,  the  nurse  had  not 
appreciated  her  condition.  Then  becoming  alarmed  at  her  appearance 
and  suftering,  she  had  given  a  large  injection  of  McMunn's  elixir  of 
opium  into  the  rectum.  She  had  also  given  some  stimulant  by  the 
mouth,  which  was  at  once  rejected  ;  a  mustard  plaster  had  been  placed 
over  the  stomach,  and  heat  had  been  applied  to  the  extremities. 
When  I  first  saw  this  woman's  face,  her  features  wore  an  expression  of 
such  extreme  suffering  that  the  impression  can  never  be  removed  from 
my  mind.  She  was  bloodless,  and  her  features  pinched  in  appearance, 
and  her  eyes  bloodshot  and  apparently  starting  from  their  sockets. 
She  would  at  one  moment  utter  the  most  piercing  single  shriek,  and 
then  bear  down  as  if  she  would  drive  the  contents  of  her  body  from  her. 
The  muscles  of  her  face  twitched,  and  her  fingers  were  finely  clenched. 
Her  skin  was  covered  with  a  clammy  sweat,  and  as  she  tossed  her 
body  to  and  fro  she  would  vomit,  and  stain  with  bile  her  night  dress  and 
the  bedclothing  about  her.  I  attempted  to  make  a  vaginal  examina- 
tion, and  felt  a  mass  like  a  child's  head  pressing  on  the  perineum, 


Fig.  45 


Eetro-uleiine  hematocele. 


and  crowding  the  uterus  above  and  behind  the  pubes,  so  that  I  could 
only  touch  the  os  uteri  with  difficulty.  I  was  unable  to  pass  my 
finger  into  the  rectum  to  a  greater  depth  than  an  inch  and  a  half, 
since  the  gut  was  firmly  compressed  into  the  hollow  of  the  sacrum. 


24.4  PELVIC    HEMATOCELE. 

While  a  finger  of  one  hand  was  in  the  rectum,  and  the  other  on  the 
abdomen,  I  could  map  out  a  hard  mass  filling  up  every  portion  of  the 
pelvis,  and  extending  into  the  abdominal  cavity  at  some  distance 
behind  the  displaced  uterus  (See  Fig.  45).  I  had  never  seen  an 
hematocele  of  such  magnitude,  and  as  I  could  not  detect  any  fluctua- 
tion I  would  have  been  unable  to  form  a  diagnosis  if  I  had  not  made 
a  careful  examination  a  short  while  before.  As  the  mass  was  below 
the  uterus,  and  between  the  vagina  and  rectum,  it  was  evident  that  a 
large  bloodvessel  had  been  ruptured.  The  blood  had  then  dissected 
up  the  recto-vaginal  septum,  crowding  the  uterus  and  bladder  forward 
above  the  symphysis,  and  lifting  at  the  same  time  the  bottom  of 
Douglas's  cul-de-sac  until  rupture  into  the  peritoneal  cavity  had 
become  imminent. 

Failing  in  an  attempt  to  reach  the  bladder  with  a  catheter,  I  made 
up  my  mind  that  the  only  course  to  follow  was  to  relieve  the  pressure 
at  once,  as  the  patient  was  now  beginning  to  sink  from  exhaustion. 
I  plunged  a  long  narrow  curved  bistoury  into  the  centre  of  the  pos- 
terior wall  of  the  vagina  as  it  protruded  from  the  separated  labia, 
but  only  a  few  drops  of  blood  escaped.  After  introducing  a  probe 
some  distance  without  resistance,  and  being  evidently  within  a  cavity, 
I  passed  in  its  place,  a  curved  canula  and  trocar  for  some  four  inches. 
On  withdrawing  the  trocar  over  thirteen  ounces  of  bloody  serum 
was  drawn  off,  with  great  relief  to  the  patient.  It  was  then  easy  to 
empty  the  bladder,  and  upon  doing  so  the  patient  became  comfortable. 
As  the  pressure  Avas  relieved  the  vomiting  ceased,  and  reaction  soon 
came  on,  aided  by  a  small  quantity  of  stimulants,  followed  by  an 
opium  enema.  After  passing  my  finger  into  the  vagina,  I  found  the 
uterus  nearly  in  a  natural  position  in  regard  to  the  sides  of  the 
pelvis,  but  much  higher  than  normal.  The  fluid  blood  above  had 
evidently  been  drawn  off",  reducing  the  bulk  about  one  third,  but  still 
leaving  a  large  mass,  or  clot,  below  the  uterus,  and  between  the 
separated  walls  of  the  vagina  and  rectum.  On  the  next  day  there 
was  some  febrile  reaction,  with  tympanites  and  a  moderate  degree  of 
tenderness  over  the  abdomen.  But  by  the  use  of  a  large  flaxseed 
poultice,  and  after  a  dose  of  oil  had  acted,  these  symptoms  passed  off". 
She  Avas  of  a  constipated  habit,  and  unfortunately  there  had  been  no 
action  of  the  bowels  for  several  days  "before  the  occurrence  of  the 
accident.  I  appreciated  fully  the  risk  of  causing  fresh  hemorrhage 
from  administering  a  purgative,  but  under  the  circumstances  it  was 
a  choice  of  what  seemed  to  be  the  lesser  evil.  On  the  third  day 
fluctuation  could  be  detected  in  the  lower  portion  of  the  mass,  while 
there  seemed  also  to  be  some  increase  in  its  size.  While  now  waiting 
in  expectation,  and  watching  the  progress  of  the  case,  the  patient  was 
kept  periectly  quiet  in  bed,  and  not  allowed  even  to  sit  up.  The  only 
treatment  consisted  in  the  employment  of  every  means  to  sustain  her 
strength.  On  the  fifth  day  she  had  a  slight  chill  with  fever,  and 
sweating  afterwards,  and  a  restless  night.  The  following  day  I  made 
a  careful  examination,  and  found  that  while  the  mass  did  not  extend 
so  high  in  the  abdomen  as  after  the  tapping,  yet  it  had  gradually  in- 


RETRO-UTERTNE    HEMATOCELE.  245 

creased  in  size  below,  so  as  to  fill  the  pelvis  almost  as  much  as  before. 
The  patient,  however,  did  not  sutter  pain  as  when  the  hematocele  was 
forming,  but  the  bowels  could  not  be  acted  on,  and  she  Avas  unable  to 
empty  the  bladder  without  the  aid  of  the  catheter.  As  there  was 
fluctuation  and  every  symptom  of  an  abscess  forming,  I  again  deter- 
mined to  puncture  with  a  bistoury  near  the  previous  opening.  On 
doing  so  a  quantity  of  offensive  pus,  bloody  serum,  and  broken-down 
clots  escaped.  The  opening  was  then  enlarged  enough  for  the  intro- 
duction of  the  finger,  when  a  large  mass  of  broken-up  clots  slowly 
passed  away.  As  there  was  no  fresh  bleeding,  the  patient  was  placed 
on  a  bed-pan,  and  while  the  edges  of  the  wound  were  kept  well  apart 
by  the  limbs  of  a  pair  of  spring  forceps,  the  cavity  was  washed  out. 
I  used  warm  water,  to  a  basin  of  which  I  added  a  sufficient  quantity 
of  Churchill's  tincture  of  iodine  to  give  it  a  decided  color.  The  iodine 
I  employed  as  a  disinfectant,  which  then  took  the  place  of  carbolic 
acid  as  used  to-day.  The  water  was  thrown  in  by  means  of  a  glass 
syringe  with  a  long  curved  nozzle.  I  very  carefully  injected  the 
water  so  as  to  wash  oif  the  sides  of  the  cavity,  from  which  the  fluid 
had  a  ready  escape  into  the  bed-pan,  I  had  a  tampon  ready,  and 
every  preparation  made  to  arrest  bleeding,  if  it  should  occur,  by  plug- 
ging the  vagina  from  about  the  uterus  downwards.  But  as  I  was 
careful  to  use  no  force,  and  as  the  position  of  the  uterus  was  not  dis- 
turbed, I  did  not  anticipate  any  bleeding  at  so  late  a  date,  unless  from 
the  walls  of  the  cavity.  This  I  felt  certain  I  could  have  controlled  by 
keeping  the  sides  in  contact  by  means  of  the  tampon  in  the  vagina. 
As  a  precaution,  however,  I  kept  a  small  portion  of  cotton  packed 
around  the  cervix  for  twenty -four  hours  afterwards,  with  a  drainage 
tent  of  lamp  wick  in  the  opening  below.  On  the  following  day  I 
again  washed  out  the  cavity  in  the  same  manner;  by  the  third  day 
the  discharge  had  greatly  diminished,  it  lessened  day  by  day  and  had 
nearly  ceased  at  the  end  of  a  week.  This  woman  made  a  very  tedious 
convalescence  from  the  great  loss  of  blood  which  she  had  sustained,  but 
at  the  end  of  three  months  she  was  walking  about,  and  with  comfort. 
As  the  cavity  contracted  it  brought  the  uterus  into  position,  and  it  no 
longer  prolapsed,  but  was  held  by  adhesions  at  some  point  in  the 
pelvis  where  the  circulation  was  no  longer  obstructed. 

The  veins  in  the  pelvis  of  this  woman  must  have  been  in  a  varicose 
condition,  and  doubtless  became  enormously  distended  as  soon  as  she 
stood  on  her  feet,  so  that  she  then  suffered  from  nausea  as  if  from  a 
sudden  loss  of  blood.  This  supposition  is  corroborated  by  the  ex- 
istence of  the  hemorrhoids,  and  the  enlargement  of  some  veins  about 
the  labia,  as  in  pregnancy. 

Evidently  a  large  vein  was  ruptured  in  the  neighborhood  of  the 
cervix  when  the  attempt  was  made  to  draw  the  neck  of  the  uterus  for- 
ward for  the  introduction  of  the  applicator.  By  pressure  of  the  clot, 
and  from  contraction  of  the  sac  afterwards,  a  large  number  of  these 
vessels  must  have  become  obliterated.  Thus  by  an  accident  a  result 
was  accomplished  which  probably  could  not  have  been  obtained  by 


2-46  PELVIC    HEMATOCELE. 

the  best  directed  measures,  or  until  nature  should  have  completed  the 
process  attending  a  change  of  life. 

Case  XII. — Mrs.  L.,  aged  32,  was  admitted  from  the  city,  Jan.  7, 
1875.  She  had  menstruated  for  the  first  time  at  12,  free  from  pain, 
the  flow  lasting  five  days ;  she  became  regular  after  six  months.  She 
had  married  at  sixteen,  bore  her  only  child  at  the  age  of  twenty  by  a 
natural  labor,  did  not  again  become  pregnant  until  three  years  before 
admission,  when  she  miscarried  at  three  months  and  a  half,  and  had 
not  been  well  since.  She  at  that  time  lived  in  New  Mexico,  and  being 
unable  to  procure  the  servants  needed  in  her  household,  she  got  up 
too  soon,  and  Avas  seized  with  an  attack  of  cellulitis,  which  kept  her 
in  bed  for  eight  months.  Since  that  time  menstruation  had  been 
irregular,  painful,  and  scanty.  She  was  unable  to  either  walk  or 
stand  without  pain  ;  her  general  health  was  very  poor,  and  she  had 
become  exceedingly  nervous.  She  had  recently  consulted  a  physician, 
in  consequence  of  an  irregular  show,  Avho  made  a  diagnosis  of  cancer, 
and  sent  her  to  me.  When  I  examined  her  for  the  first  time,  I 
felt  what  seemed  to  be  an  epithelioma  on  the  cervix ;  the  uterus  was 
enlarged,  and  tilted  somewhat  to  the  left  side,  from  the  shortening  of 
the  left  broad  ligament  after  a  cellulitis.  I  could  give  with  the  finger 
a  certain  degree  of  rotatory  movement  to  the  growth  on  the  cervix,  in 
which  the  uterus  itself  did  not  participate.  She  was  placed  on  the 
side,  and  on  the  introduction  of  the  speculum  I  discovered  that  a  large 
mucous  polypus  had  been  forced  out  of  the  uterus,  but  with  a  pedicle  so 
short  that  the  mass  was  crowded  over  the  cervix,  covering  it  almost  as 
a  percussion  cap  would  the  nipple  of  a  fowling-piece.  The  traction 
of  the  pedicle  was  sufficient  to  obstruct  the  circulation,  so  that  the 
color  closely  resembled  that  of  epithelioma,  and  its  surface  had  be- 
come irregular  and  granular.  In  fact,  it  required  a  good  light  to 
determine  its  true  character.  Jan.  11,  I  removed  the  mass  in  the 
presence  of,  and  after  a  careful  examination  had  been  made  of  the 
case  by,  my  assistants,  Drs.  George  T.  Harrison  and  Bache  Emmet. 
I  tightened  a  slip-knot  of  coarse  twine,  which  found  its  way  around 
the  pedicle,  and  during  traction  an  edge  of  the  mass  was  lifted,  so  as 
to  bring  into  view  the  pedicle,  which  was  divided  with  a  pair  of  scissors. 
To  add  to  the  deception,  an  opening  existed  where  the  os  should  have 
been,  and  the  probe  could  be  passed  for  some  distance  in  the  direc- 
tion of  the  pedicle.  When  it  was  removed,  there  remained  on  the 
under  side  a  deep  depression,  as  would  be  found  in  a  half-gi*own  mush- 
room. 

Her  recovery  after  so  simple  an  operation  was  tedious,  and  she 
complained  frequently  of  pain  in  the  left  side,  but  only  where  she  had 
often  had  it  previous  to  the  operation.  On  examination  a  slight 
thickening-  and  some  tenderness  were  detected  along  the  left  broad 
ligament.  Hot  water  vaginal  injections  were  ordered,  and  the  fre- 
quent application  of  iodine  over  the  lower  portion  of  the  abdomen. 
Ten  days  after  the  operation,  Jan.  21,  the  period  returned  out  of  time, 
and  was  very  free  ;  she  was  kept  in  bed,  but  with  no  other  treatment 


HEMATOCELE    IN    THE    PERITONEUM. 


247 


beyond  that  directed  to  improve  her  general  condition.  Feb.  12,  the 
menstrual  flow  retvirncd,  and,  as  it  was  very  free,  she  was  still  kept  in 
bed.  Two  days  later  a  lari^e  clot  was  expelled  by  uterine  contractions, 
and  shortly  afterwards  another,  with  the  same  character  of  pain. 
She  was  then  seized  with  a  severe  pain  over  the  left  side,  and  this 
was  followed  by  a  chill.  On  making  an  examination  it  was  found 
that  the  thickening  had  increased  in  the  broad  ligament  to  nearly  the 
size  of  a  hen's  egg.  A  poultice  was  applied  over  the  abdomen,  and 
opium  administered  by  the  rectum.  For  some  hours  afterward  she 
had  profuse  sweating,  which  was  attributed  to  the  effect  of  the  opium. 
The  flow  now  became  too  free,  and  gallic  acid  with  cinnamon  Avater 
was  given  every  two  hours,  but  there  had  remained  no  pain  after 
applying  the  poultice  on  the  14th  instant.  Feb.  18,  she  called  my 
attention  to  an  enlargement  in  her  abdomen.  After  making  a  vaginal 
examination  I  found  a  large  mass  on  the  left  side,  extending  a  little 
above  the  crest  of  the  ilium  and  backward,  filling  up  the  posterior 
cul-de-sac.  The  uterus  Avas  in  the  midst  of  the  mass,  and  but  little 
displaced  beyond  a  partial  prolapse   (see  Fig.  46).     There  was  no 

Fig.  46. 


Hematocele  in  the  peritoneum. 

tenesmus  or  irritation  of  the  bladder,  the  temperature  was  101°  in 
the  vagina,  and  the  patient  was  even  unwilling  to  remain  in  bed.  A 
certain  amount  of  cellulitis,  which  had  existed  before,  was  rekindled 
after  the  operation,  and  rupture  took  place  through  the  folds  of  the 
broad  ligament  into  the  peritoneal  cavity,  but  the  blood  was  thrown 
out  so  slowly  that  no  marked  symptoms  were  excited.     This  was  sup- 


248  PELVIC    HEMATOCELE. 

posed  to  have  been  the  course,  yet  the  hemorrhage  may  have  escaped 
from  the  surface  of  the  ovary.  The  flow  stopped  Feb.  19,  and  again 
returned  March  14,  but  "with  less  pain  than  usual,  and  lasted  only  four 
days.  She  was  then  placed  on  large  doses  of  the  iodide  of  potassium, 
and  after  this  had  been  taken  for  some  twelve  days,  it  was  noticed 
that  from  some  cause  the  clot  was  being  rapidly  absorbed.  Soon  she 
was  able  to  get  out,  and  on  March  27,  an  excitement,  consequent  upon 
having  had  her  pocket  picked,  brought  on  the  flow,  which  lasted  until 
April  7.  Thirteen  days  later,  in  consequence  of  over-exertion,  she 
again  had  a  flow,  which  lasted  six  days.  May  2,  ordered  a  blister, 
as  the  uterus  was  still  enlarged  and  immovable,  but  the  mass  in  the 
cul-de-sac  had  disappeared,  and  the  one  through  the  abdominal  wall 
on  the  left  side  had  been  greatly  reduced  in  size.  On  March  4,  it  was 
found  that  an  increase  in  the  size  of  the  mass  had  taken  place  ;  she 
had  felt  listless  for  several  days  previous.  She  gradually,  however, 
improved,  and  on  her  return  home,  about  the  middle  of  June,  the  mass 
had  so  far  disappeared  that  it  would  have  been  overlooked  by  any 
one  not  familiar  with  her  history. 

This  case  illustrates  in  a  marked  manner  the  differences  in  the  de- 
gree of  disturbance  met  with  in  such  cases.  The  effusion  of  blood  was 
as  great  as,  if  not  even  greater  in  quantity  than,  with  the  first  case, 
and  yet  the  accumulation  took  place  so  gradually  and  imperceptibly, 
as  to  attract  no  attention. 

The  following  case  occurred  in  the  Woman's  Hospital  while  I  was 
Surgeon-in-Chief,  and  in  the  service  of  Dr.  Harrison.  I  quote  the 
case  as  cited  by  him  in  his  paper^  already  referred  to. 

Case  XIII.— "i^eJ.  15,1871.  Mrs.  A.  F.  was  admitted  to  the  Wo- 
man's Hospital  with  the  following  history :  Menstruation  appeared  first 
at  the  age  of  eighteen,  and  until  within  the  past  two  years  showed  no 
abnormal  features.  She  was  married  at  the  age  of  twenty;  her  hus- 
band died  not  long  after  marriage.  At  the  age  of  twenty-seven, 
married  the  second  time.  Has  never  been  pregnant.  About  two 
years  ago  began  to  suffer  with  dysmenorrhoea.  Leucorrhoea  has  also 
been  a  symptom  of  late.  Three  months  ago,  was  seized  with  a  severe 
pain  in  the  hypogastric  region,  which  confined  her  to  bed  two  weeks. 
The  pain  was  so  intense  that  it  could  only  be  alleviated  by  large  doses 
of  opium  internally,  and  the  application  of  hot  poultices  to  the  abdomen. 
The  period  recurs  regularly,  but  is  scanty,  and  the  dysmenorrhoea 
now  gives  rise  to  more  suffering;  bowels  constipated;  appetite  poor. 

"  23cZ.  Examined  by  Dr.  Emmet,  who  diagnosticated  a  chronic 
perimetric  inflammation. 

"Marc/i  2.  Patient  left  the  hospital  on  account  of  domestic  reasons. 

'■'■January  IS,  1873.   Keadmitted  into  the  hospital.     She  came  now 

'  Retro-uterine  Hematocele,  etc.,  by  George  T.  Ha^rrisoii,  A.M.,  M.D.,  Assistant 
Surgeon  to  the  Woman's  Hospital  of  the  State  of  New  York;  Virginia  Medical 
Monthly,  Oct.  and  Nov.  1875. 


RETRO-UTERINE    HEMATOCELE.  249 

under  my  immediate  care  and  observation,  as  the  Assistant  Surgeon 
on  duty  at  the  time ;  Dr.  Emmet  seeing  her  from  time  to  time,  ac- 
cording to  the  routine  of  the  hospital,  and  giving  me  the  benefit  of 
his  counsel  and  experience.  The  period  is  now  more  protracted  and 
copious  than  formerly,  and  is  attended  with  similar  pains.  Dr. 
Emmet's  examination  showed  the  existence  of  retroversion  of  the 
uterus  with  pseudo-membranous  attachments  to  the  rectum,  the  result 
of  partial  peritonitis.  As  part  of  the  treatment,  a  pessary  was  intro- 
duced into  the  vagina,  Avith  the  hope  that  by  its  lever-like  action  the 
pseudo-ligaments  would  be  gradually  stretched,  and  undergo  atrophy, 
and  the  uterus  ultimately  be  restored  to  its  normal  position.  It  was 
proven,  however,  that  there  existed  so  much  tenderness  in  the  poste- 
rior fornix  vaginte,  that  no  pessary  that  could  be  placed  in  situ  could 
be  worn  for  any  length  of  time,  though  the  shape  was  modified 
repeatedly  to  meet  the  exigencies  of  the  case. 

"31s^.  The  last  time  the  pessary  was  adjusted  the  patient  suffered, 
for  a  few  hours  afterwards,  a  good  deal  of  pain,  and,  according  to 
instructions,  she  removed  it.  The  tissues  posterior  to  the  uterus 
Avere  so  sensitive  on  pressure  that  the  patient  was  ordered  to  keep 
her  bed  for  several  days,  and  to  use  repeated  injections  of  hot  water. 

^'■Feb.  5.  As  the  patient  walked  into  the  operating  room,  I  was 
struck  with  her  exceedingly  pallid  countenance  and  entire  change  of 
appearance  since  ray  last  visit.  She  says  that  she  has  been  feeling 
worse  for  the  past  few  days,  has  now  a  bearing-down  sensation  in  the 
pelvis,  difficulty  of  defecation  and  urination;  feels  very  Aveak  and 
faint,  though  she  has  walked  but  a  few  steps,  assisted  by  the  nurse, 
her  bed  being  in  the  adjacent  Avard  but  a  short  distance  aAvay.  Ex- 
amination per  A'aginam  revealed  the  existence  of  a  large  globular 
elastic  tumor,  Avhich  has  dislocated  the  uterus  forAvards  against  the 
symphysis  pubis,  and  Avas  just  behind  the  portio  vaginalis,  pressing  the 
posterior  fornix  vaginae  doAvnwards,  and,  as  investigation  per  rectum 
showed,  encroaching  largely  on  the  sacral  cavity.  Bimanual  palpation 
demonstrated  clearly  that  the  tumor  Avas  distinct  from  the  uterus  and 
immediately  posterior  to  it.  There  Avas  no  elevation  of  temperature 
or  other  evidence  of  fever.  There  had  been  no  discharge  of  blood 
through  the  vagina,  and  it  was  not  the  time  for  the  recurrence  of  the 
menstrual  period.  It  should  be  remarked  that  the  colon  Avas  found 
a  day  or  tAvo  afterwards  loaded  Avith  fecal  matter,  wdiich  Avas  dislodged 
with  difficulty  by  copious  injections,  and  it  is  possible  that  this  accumu- 
lation may  have  had  some  bearing  upon  the  etiology  of  the  trouble. 
The  rapid  manner  in  Avhich  the  extravasated  blood  Avas  absorbed  in 
this  case  was  very  remarkable,  and  tended  to  confirm  the  truth  of 
Voisin's  statement  that  'the  tumor  from  the  moment  of  its  develop- 
ment shoAvs  the  endeavor  to  diminish.'  " 

The  history  of  this  case  is  of  interest,  since  the  occurrence  of  the 
hematocele  had  no  connection  Avith  the  menstrual  floAv.  After  detailing 
the  history  of  another  case,  Dr.  Harrison  summarizes  in  the  following 
manner:  "The  fair  and  legitimate  inference  to  be  drawn  from  the 


250  PELVIC    HEMATOCELE. 

clinical  history  of  these  two  cases  is,  we  think,  that  here  was  a 
primary  closure  of  Douglas's  cul-de-sac,  and  secondarily  an  effusion 
of  blood  into  the  closed  space  there  formed;  and  that  the  partial 
pelvic  peritonitis,  recognized  in  each  case  prior  to  the  development  of 
the  hematocele ,  not  only  furnished  the  pseudo-membranes  roofing  the 
Douglas's  space,  but  also  gave  origin  to  the  hemorrhage  in  the  way 
described  by  Dolbeau,  Virchow,  and  Ferber." 

Case  XIV. — Mrs.  Van  B.,  of  Newark,  aged  27,  consulted  me  De- 
cember 6,  1871.  She  menstruated  for  the  first  time  at  fifteen,  after 
"which  she  had  been  regular,  and  was  in  good  health  when  married  at 
eighteen  years  of  age.  One  year  afterwards  she  gave  birth  to  her 
only  child  by  a  natural  labor.  Subsequently  the  period  gradually 
became  more  painful  throughout  the  first  day,  and  increased  in  dura- 
tion from  five  to  eight  days.  For  a  long  time  she  had  had  a  profuse 
vaginal  discharge  for  several  days  after  the  period  had  ceased.  She 
had  been  able  to  walk  and  stand  without  flifficulty,  unless  she  had 
over-exerted  herself,  when  there  would  come  on  a  pain  low  down  in 
the  back.  She  had  been  married  a  second  time  five  years,  and  sought 
advice  for  the  increasing  dysmenorrhoea  and  sterility. 

The  uterus  was  found  retroverted,  with  the  cervix  near  the  neck  of 
the  bladder,  and  the  vagina  extending  beyond  into  a  deep  cul-de-sac. 
A  small  mass,  not  larger  than  half  an  inch  in  diameter,  was  detected 
in  front  of  the  right  broad  ligament,  just  above  the  vaginal  junction  ; 
in  other  w^ords,  it  was  in  the  angular  space  formed  by  the  ligament, 
uterus,  bladder,  and  vagina.  This  was  supposed  to  be  a  fibroid, 
and  that  from  its  situation  it  would  aid  in  causing  retroversion  of 
the  uterus  whenever  the  bladder  became  distended.  The  position  of 
the  uterus,  and  the  deep  vagina  beyond,  was  thought  to  have  been  a 
sufficient  cause  for  the  sterility.  The  organ  was  replaced  without 
difficulty,  and  a  pessary  was  fitted  to  retain  it  in  position.  Within  a 
week  she  became  pregnant,  when,  without  any  known  cause,  she 
miscarried  March  1, 1872,  at  nearly  the  completion  of  the  third  month. 

23c?.  Without  consulting  her  physician  she  made  the  journey,  on 
an  inclement  day,  to  consult  me  in  regard  to  a  constant  show  which 
had  continued  since  her  miscarriaore,  for  over  three  weeks.  She  was 
flowing  very  freely  when  I  saw  her  in  my  office,  which,  together  with 
the  weather  and  her  appearance  as  that  of  a  very  sick  woman,  made 
me  think  it  best  to  retain  her.  She  was  placed  on  the  elevator,  taken 
up-stairs,  and  put  to  bed  in  my  private  hospital.  For  several  days  I 
tamponed  the  vagina,  but  it  caused  a  great  deal  of  irritation  in  the 
neighborhood  of  the  supposed  fibroid.  This  mass  could  not  now  be 
felt,  but  in  its  place  there  was  a  diffused  thickening,  apparently  more 
in  the  vagina  than  in  the  cellular  tissue  beyond.  The  uterine  cavity 
was  carefully  explored,  by  means  of  my  curette  forceps,  to  determine 
as  to  the  retention  of  some  portion  of  the  placenta,  but  there  was 
nothing  within  the  canal.  She  was  kept  in  bed,  and  iodine  was 
applied  for  several  days  with  partial  success.     Large  vaginal  injec- 


RUPTURE    INTO    THE    PERITONEUM.  251 

tions  of  hot  water  were  administered  night  and  morning,  and  they 
were  apparently  more  efficacious  in  checking  the  flow  than  any  other 
means  employed.  But  the  patient  was  both  unreasonable  and  un- 
governable, so  that  she  would  not  submit  to  taking  them  through  fear 
that  the  use  of  hot  water  might  weaken  her.  On  Monday,  April  8, 
I  found  her  so  irritable  and  fault-finding,  from  the  continuation  of  the 
show,  that  I  asked  Dr.  T.  (t,  Tiiomas  to  see  her  in  consultation.  He 
recommended  the  application  of  tannin  to  the  uterine  canal,  made  up 
with  cocoa-butter  into  a  proper  shape.  One  of  these  cylinders  I 
introduced  at  noon  on  the  following  day  without  difficulty,  as  she  lay 
on  the  left  side  with  the  os  uteri  exposed  from  the  use  of  the  speculum. 
The  table  Avas  then  moved  up  alongside  of  her  bed,  so  that  she  might 
roll  carefully  upon  it,  but  instead  of  doing  so  she  stood  up  and  flounced 
herself  down  on  the  bed  in  so  violent  a  manner  that  I  remarked  she 
ought  to  be  ashamed  of  herself.  There  was  no  show  after  the  use  of 
the  tannin,  but,  instead  of  being  encouraged,  the  nurse  informed  me 
that  she  was  more  depressed  than  usual.  At  8  P.  M.  she  began  to 
suffer  from  pain  over  the  abdomen,  and  I  directed  a  drachm  of  Mc- 
Munn's  elixir  to  be  thrown  into  the  rectum.  But  she  began  to  vomit 
before  it  had  any  effect,  but  after  receiving  a  hypodermic  injection  of 
morphine,  and  a  poultice  over  the  abdomen,  she  spent  a  quiet  night. 
The  temperature  was  98.5°;  the  pulse  106,  and  weak.  On  the  fol- 
lowing morning,  the  pain  and  vomiting  returned.  I  made  a  vaginal 
examination,  detecting  nothing  unusual,  that  is,  I  found  nothing  in 
the  posterior  cul-de-sac,  but  I  neglected  to  place  my  hand  over  the 
abdomen,  as  it  was  covered  with  a  poultice.  She  was  kept  compara- 
tively quiet  during  the  day  by  injecting  several  times  a  drachm  of 
chloroform,  holding  in  solution  an  equal  quantity  of  camphor,  into  the 
rectum.  But  it  was  most  evident  that  she  was  sinking,  and  yet  suf- 
fered but  little  if  any  pain.  At  5  P.  M.  she  began  to  show  symptoms 
of  collapse,  with  vomiting  and  more  pain.  Dr.  Thomas  saw  her  with 
me  at  8  P.  M.,  and  on  examining  the  abdomen  the  presence  of  a  mass 
on  the  right  side  of  the  bladder  was  at  once  evident.  He  then  sug- 
gested the  existence  of  a  hematocele,  which  had  not  occurred  to  me, 
from  its  being  in  so  unusual  a  place.  I  had  recognized  the  symptoms 
as  characteristic  of  hematocele,  but  found  nothing  in  the  posterior 
cul-de-sac  or  broad  ligaments ;  and  I  neglected  to  examine  the  abdo- 
men. How  many  hours  this  accumulation  had  been  sufficiently  great 
to  be  prominent  through  the  abdominal  walls  cannot  be  answered ;  it 
may  have  had  its  beginning  at  five  o'clock.  The  pain  gradually  in- 
creased in  severity,  so  that  no  amount  of  morphine,  either  by  rectum 
and  under  the  skin,  seemed  to  be  of  any  benefit.  About  midnight 
she  suddenly  gave  a  most  piercing  scream,  and,  starting  out  of  bed, 
wild  with  suffering,  she  exclaimed  that  her  insides  were  being  torn  to 
pieces.  In  ten  minutes  the  stamp  of  death  was  on  her  features,  and 
yet,  for  six  hours  before  she  died,  she  seemed  unable  to  remain  quiet 
a  single  second,  and,  at  last,  she  dropped  dead  from  exhaustion. 

On  opening  the  abdomen  the  lower  portion  of  the  peritoneal  cavity 
was  found  filled  with  a  large  clot  which  covered  the  pelvic  organs. 


252 


PELVIC    HEMATOCELE. 


Removing  this  clot  carefully,  it  was  found  that  the  hemorrhage  had 
commenced  in  the  cellular  tissue  in  front  of  the  right  broad  ligament. 
It  had  lifted  the  peritoneum  throughout  from  the  anterior  face  of  the 
broad  ligament,  partially  from  the  side  of  the  bladder,  and  entirely 
between  the  uterus  and  bladder.  After  this  anterior  fossa  had  be- 
come filled  with  blood,  and  had  lifted  the  peritoneum,  as  has  been 
described,  rupture  took  place  to  the  right  of,  and  in  a  line  with,  the 
centre  of  the  broad  ligament.  The  blood  then  escaped  into  the  perito- 
neal cavity  and  occupied  about  the  relative  space  shown  in  Fig.  47. 

Fig.  47. 


Hematocele  ruptured  into  the  peritoneum. 

The  friends  were  so  unwilling  to  permit  an  examination  that  a  par- 
tial consent  was  only  obtained  at  the  last  moment,  by  a  threat  of  pla- 
cing the  case  in  the  hands  of  the  coroner.  Unfortunately  therefore 
we  had  neither  the  time  nor  the  opportunity  for  removing  the  specimen 
or  of  even  finding  the  ruptured  vessel. 

This  form  of  thrombus  or  hematocele,  when  anterior  to  the  uterus, 
is  exceedingly  i-are,  and  I  believe  unique,  in  this  locality,  as  I  cannot 
find  a  similar  ca^se  on  record. 

Differential  Diagnosis. — Hematocele  can  scarcely  be  mistaken  for 
any  other  condition  except,  under  certain  circumstances,  that  of  extra- 
uterine pregnancy  or  cellulitis.  It  is  scarcely  necessary  to  refer  to 
retroversion  of  the  uterus,  when  enlarged  from  pregnancy  or  congestion, 


DIFFERENTIAL    DIAGNOSIS.  253 

or  to  the  presence  of  ascitic  fluid,  ovarian  cyst,  or  a  fibroid  in  Doug- 
las's cul-de-sac.  Neither  of  these  conditions  presents  in  common  -with 
hematocele  such  symptoms  as  could  lead  to  any  confusion  if  an  ordi- 
nary amount  of  care  is  exercised  in  the  examination. 

A  positive  diagnosis,  however,  cannot  always  be  made,  by  a  single 
examination,  for  the  existence  of  pregnancy  is  possible  within  the  peri- 
toneal cavity  at  the  bottom  of  Douglas's  cul-de-sac.  And,  moreover,  if 
a  rupture  should  have  taken  place,  or  if  cellulitis  should  have  been  ex- 
cited, the  difficulties  of  a  diagnosis  would  be  increased.  We  will  have 
to  rely  chiefly  on  the  previous  history  of  the  case,  as  to  the  early  signs 
of  pregnancy.  While  in  all  probability  a  frequent  show  may  have 
been  noticed,  there  will  have  been  no  regular  menstrual  period,  and 
the  uterus  will  be  found  always  larger  than  natural. 

With  tubal  pregnancy  the  tumor  will  be  found  too  well  defined  in 
shape,  when  compared  to  the  condition  resulting  from  an  extravasation 
of  blood  between  the  folds  of  the  broad  ligaments  ;  in  this  the  blood 
tumor  always  becomes  blended  with  the  side  of  the  uterus  itself.  In 
tubal  pregnancy,  however,  the  enlargement  of  the  uterus  and  the 
frequent  occurrence  of  a  show,  in  the  continued  absence  of  the  regular 
menstrual  flow,  will  be  found  the  most  reliable  symptoms. 

During  the  formation  of  a  hematocele  there  is  never  an  elevation 
of  temperature,  as  Avith  cellulitis  or  peritonitis,  but  on  the  contrary 
the  prominent  features  are  those  of  depression.  When  an  extravasa- 
tion has  taken  place  into  the  connective  tissue,  a  finger  in  the  vao-ina 
will  only  detect  an  irregular  surface,  due  to  the  blood  having  met  with 
more  or  less  resistance  in  its  course.  On  the  other  hand,  when  blood  ac- 
cumulates in  Douglas's  cul-de-sac,  a  smooth,  rounded  and  well-defined 
mass  will  characterize  the  shape  of  this  pouch,  when  felt  from  the  vagina. 
This  outline  becomes  lost  in  the  event  of  either  cellulitis  or  peritonitis, 
while  inflammation  imparts  a  degree  of  density  to  these  tissues,  which 
is  never  felt  in  connection  with  a  simple  efliision  of  blood. 

A  rare  form  of  hematocele  has  been  described  which  might  be  mis- 
taken for  inflammation  of  the  broad  ligaments  or  general  cellulitis,  if 
merely  a  superficial  examination  were  made.  It  is  when  the  blood 
has  been  thrown  out  in  such  a  quantity  as  to  distend  the  fold  of  one 
broad  ligament,  and  then,  instead  of  rupturing  into  the  peritoneum,  it 
dissects  this  membrane  from  the  sides  of  the  uterus,  so  as  to  pass  into 
the  cellular  tissue  of  the  other  broad  ligament.  This  general  extra- 
vasation may  put  the  parts  so  much  on  the  stretch  as  to  simulate 
somewhat  the  condition  caused  by  inflammation.  If  such  an  extent  of 
tissue  was  involved  by  cellulitis,  the  symptoms  would  be  so  diff'erent 


254  PELVIC    HEMATOCELE. 

from  those  which  have  been  detailed  for  hematocele  that  there  would 
be  no  difficulty  in  making  a  correct  diagnosis. 

Treatment. — But  little  more  can  be  added  to  this  portion  of  the 
subject  beyond  what  has  been  already  given  in  the  histories  of  the 
cases  detailed.  Surgical  interference  has  been  advocated  by  many, 
and  its  practice  has  been  urged  as  a  necessary  procedure  at  an  early 
stage.  Unquestionably  cases  must  occur  when  the  surgeon  would  be 
wanting  in  a  sense  of  duty  if  he  did  not  assume  the  responsibility 
and  puncture  the  mass.  But  Avith  a  large  majority  of  cases  such  an 
interference  would  be  criminal,  as  it  needlessly  places  the  life  of  the 
patient  in  jeopardy. 

As  a  rule,  nature  makes  a  prompt  eifort  to  repair,  by  absorption,  the 
result  of  this  accident,  and,  unquestionably,  the  lesion  occurs  and  is 
often  removed  without  its  existence  having  been  suspected.  Absolute 
rest  in  the  horizontal  position  is  the  first  indication,  and  this  must  be 
maintained  until  all  danger  of  a  recurrence  of  the  hemorrhage  has 
passed.  The  application  of  an  ice-bag  to  the  abdomen  and  the  use 
of  ergot  have  been  recommended,  but  I  doubt  the  value  of  either 
remedy.  It  is  not  improbable  that  any  good  effect  from  the  use  of 
cold  in  arresting  the  hemorrhage  would  be  more  than  counterbalanced 
by  the  risk  of  exciting  inflammation.  Ergot  in  small  doses  may  exert 
some  eifect  on  the  coats  of  the  bloodvessels  if  given  hypodermically, 
while  it  would  be  apt  to  derange  the  stomach  if  taken  internally. 

I  would  trust  more  to  a  cool  room,  light  bedclothing,  absolute  rest, 
and  opium,  if  needed,  with  a  moderately  tight  abdominal  bandage. 
The  tendency  is  to  form  a  clot  about  the  mouth  of  the  bleeding  vessel, 
which  will  do  more  than  anything  else  to  arrest  the  hemorrhage,  if  it 
is  not  disturbed.  It  will  be  prudent  for  the  patient  to  remain  quiet 
in  bed  during  the  approach  of  the  next  menstrual  period,  for  fear  of 
causing  a  recurrence  of  the  hemorrhage. 

As  the  rapidity  with  which  the  clot  will  be  removed  will  depend 
upon  the  state  of  the  general  health,  every  effort  must  be  made  to 
improve  it.  The  value  of  large  and  continued  doses  of  the  iodide  of 
potassium  in  producing  absortion  of  the  clot  has  yet  to  be  tested  by 
further  observation.  Should  cellulitis  occur,  the  complication  mvist 
be  met  on  general  principles,  as  if  it  were  the  original  aft'ection.  The 
continued  use,  however,  of  hot  water  vaginal  injections  will  not  only 
lessen  the  liability  to  this  complication,  but  will  hasten  materially  the 
absorption  of  the  clot. 


CELLULITIS.  255 


CHAPTER    XIII. 

DISEASES  OF  THE  PELVIC  CELLULAR  TISSUE. 

Description  of  the  tissues — The  influence  of  cellulitis  not  fully  appreciated  as  a 
cause  of  disease  in  the  uterus  and  ovaries — Etiology — Symptoms  and  treatment 
of  cellulitis — Tables  showing  the  causes,  complications,  and  location  of  cellu- 
litis, and  the  condition  of  the  menstrual  flow  as  influenced  by  cellulitis — Symp- 
toms— Treatment — Dr.  Brickell's  conclusions. 

Throughout  the  pelvis,  in  the  intervening  spaces  between  the 
bladder,  uterus,  and  rectum  above,  and  about  the  vagina  and  rectum 
below,  is  found  the  cellular,  or  connective  tissue.  This  tissue  serves 
the  purpose  of  steadying  the  organs,  and  from  its  elastic  character  it 
breaks,  like  a  cushion,  the  force  or  jar  which  would  otherwise  be  felt 
with  every  step.  The  bloodvessels  and  nerves  are  distributed  by 
means  of  this  tissue,  which  is  well  fitted  for  the  purpose,  from  its 
peculiar  web  or  sponge-like  formation.  Its  character  admits  of  a 
great  degree  of  traction  being  exerted  upward  (as  in  pregnancy),  or 
downward  (as  in  prolapse),  without  impairing  the  integrity  of  either 
bloodvessels  or  nerves. 

Above  is  found  the  peritoneum,  reflected  from  the  abdominal  wall 
in  front,  over  the  anterior  and  upper  third  of  the  bladder,  to  the  body 
and  fundus  of  the  uterus.  Then  dipping  posteriorly,  an  inch  or  more 
below  the  vaginal  junction,  to  form  Douglas's  cul-de-sac,  it  passes 
backward,  to  cover  the  anterior  face  of  the  rectum.  The  peritoneum 
thus  invests  the  organs  of  the  pelvis  as  any  pliant  covering  would  do, 
by  dipping  down  suiBciently  on  all  sides  to  conform  to  the  general 
outline  of  the  upper  portion  of  these  organs.  As  it  thus  passes 
down  between  the  organs  and  over  the  Fallopian  tubes,  it  includes 
a  certain  amount  of  this  cellular,  or  connective,  tissue  between  its 
folds,  and  with  this  and  a  few  muscular  fibres  forms  the  uterine  lio-a- 
ments.  The  broad  ligament  includes  the  Fallopian  tube  on  each  side 
of  the  uterus.  In  the  same  manner,  the  utero-sacral  ligaments  are 
formed  behind. 

Inflammation  of  this  tissue  is  generally  termed  cellulitis,  which  is 
sufficiently  accurate  for  all  practical  purposes.  The  terms  perimetritis, 
meaning  inflammation  of  the  pelvic  peritoneum,  and  parametritis,  ex- 


256  DISEASES    OF    THE    PELVIC    CELLULAR    TISSUE, 

pressing  inflammation  of  the  cellular  tissvie  about  the  uterus,  were 
recommended  by  Virchow.  But  these  terms,  like  many  others  in  use, 
express  a  theoretical  distinction  only,  since  the  difference  cannot  be 
recognized  in  practice.  At  least,  I  must  acknowledge  my  own  inability 
to  make  any  distinction  at  the  bedside.  It  is  inconceivable  that  in- 
flammation of  any  portion  of  the  pelvic  peritoneum  could  exist  without 
involving  the  cellular  tissue  in  connection  with  it.  Xor  is  it  possible 
that  extensive  cellular  inflammation  could  run  its  course  without  ex- 
tending to  the  peritoneal  covering,  which  is  in  such  close  relation  with 
it.  We  certainly  cannot  have  extensive  cellulitis  without  pelvic  peri- 
tonitis, which  may  become  general. 

A  general  peritonitis  may  involve  the  pelvic  peritoneum,  although 
this  is  not  usual ;  or  local  inflammation  may  be  excited  by  the  contact 
of  some  solid  or  fluid  material  escaping  from  the  uterus  or  its  appen- 
dages. Yet,  whatever  the  exciting  cause  may  be,  pelvic  peritonitis 
cannot  exist  alone,  but  must  rapidly  involve  the  cellular  tissue  invested 
by  it. 

This  inflammation  may  be  confined  to  either  broad  ligament,  to  the 
posterior  cul-de-sac,  to  the  space  between  the  uterus  and  bladder,  or 
it  may  be  general. 

I  do  not  exaggerate  when  I  claim  that  this  disease  is  by  far  the 
most  important  one  with  which  woman  is  afflicted.  It  is  the  most  com- 
mon, and  becomes  the  more  important,  in  being  comparatively  seldom 
recognized.  It  seems  scarcely  possible  that  any  one  with  the  slightest 
experience  could  overlook  an  extensive  cellulitis,  whether  confined  to 
one  side,  or  general  in  extent.  At  least  the  existence  of  some  great 
pathological  change  ought  to  be  detected  under  these  circumstances, 
which  of  itself  would  be  sufficient  protection  for  the  patient  against 
any  procedure  likely  to  aggravate  her  condition.  But  I  do  not  hesitate 
to  make  the  assertion,  as  a  truth  based  on  my  own  knowledge,  that 
many  practitioners  habitually  neglect  to  recognize  this  condition, 
when  circumscribed,  or  they  do  not  appeciate  its  importance  if  by 
accident  it  be  detected.  Many  of  the  disappointments  and  the  bad 
results  so  often  complained  of  in  the  management  of  the  diseases  of 
women,  in  general  practice,  may  be  attributed  to  the  existence  of 
unrecognized  cellulitis.  Its  undetected  presence  may,  to  the  end, 
thwart  all  efforts  of  treatment,  or  may  gravely  complicate  the  case 
by  suddenly  developing  to  a  most  serious  extent.  A  great  advance 
in  the  treatment  of  the  diseases  of  women  will  be  made  whenever 
practitioners  become  so  impressed  with  the  significance  of  cellulitis  as 
to  apprehend  its  existence  in  every  case.     The  successful  operator 


CELLULITIS.  257 

in  this  branch  of  surgery  -will  be  he  who  is  always  on  the  lookout  for 
the  existence  of  cellulitis,  or  who  is  taking  measures  to  guard  against 
its  occurrence. 

When  a  patient  is  examined  for  the  first  time,  the  starting  point 
should  be  to  determine  the  existence  of  the  slightest  trace  of  cellulitis. 
This  knowledge  is  absolutely  necessary  before  Ave  can,  with  safety, 
conduct  the  subsequent  steps  of  the  examination.  When  the  finger  is 
introduced  into  the  vagina,  it  should  be  passed  first  to  one  side,  and 
then  to  the  other  of  the  uterus,  to  detect  any  existing  thickening  in 
either  broad  ligament,  which  would  indicate  this  disease.  If  the  neck 
of  the  uterus  were  found  drawn  to  one  side  of  the  vagina,  this  we 
Avould  recognize  as  the  effect  of  a  former  attack  of  cellulitis,  which 
resulted  in  shortening  of  the  ligament  on  that  side.  With  one  hand 
over  the  abdomen,  and  the  index  finger  of  the  other  in  the  vagina,  it 
Avill  be  easy  to  judge  of  the  extent  of  thickening,  or  whether  the  disease 
be  still  smouldering,  as  it  were,  as  evidenced  by  the  pain  produced  on 
pressure.  The  posterior  cul-de-sac  must  be  afterward  subjected  to 
the  same  careful  examination.  The  investigation  is  to  be  completed 
by  introducing  the  finger  into  the  rectum,  where  we  may  detect,  from 
the  tenderness  excited  on  pressure,  any  local  inflammation  in  the 
upper  part  of  the  broad  ligament.  The  examination  by  the  rectum 
should  never  be  omitted,  for  extensive  disease  might  exist  in  the  upper 
part  of  the  broad  ligament  along  the  course  of  the  Fallopian  tubes,  or 
in  the  ovaries,  which  could  not  be  recognized  from  the  vagina.  During 
the  course  of  the  examination  thus  conducted,  the  position,  size,  and 
mobility  of  the  uterus  can  be  accurately  appreciated. 

Inflammation  of  the  pelvic  cellular  tissue  may  exist  in  any  degree 
from  simply  a  point  of  tenderness,  only  to  be  detected  on  pressure,  to 
a  general  cellulitis.  The  impression  conveyed  to  the  finger  by  the 
latter  condition,  would  be  as  if  the  cellular  tissue,  while  in  a  fluid 
state,  had  been  poured  into  the  pelvis  about  the  organs,  and,  after 
filling  every  interstice,  had  become  solid.  When  the  inflammation 
has  been  confined  chiefly  to  the  peritoneum,  and  the  cellular  tissue 
connected  with  it,  the  anterior  wall  of  the  vagina  will  become  tense 
from  the  lateral  traction  exerted  by  the  inflamed  tissues.  The  sensa- 
tion then  conveyed  to  the  finger  would  be  as  if  a  cardboard  blocked 
up  the  pelvic  canal,  and  the  neck  of  the  uterus  Avould  be  felt  fixed 
and  as  if  presenting  through  an  opening  barely  large  enough  for  its 
passage.  This  condition  would  represent  inflammation  of  the  pelvic 
roof,  involving  the  peritoneum  throughout  the  pelvis  in  a  plane  ex- 
tending from  the  sub-pubic  ligament  to  the  attachment  of  the  utero- 
17 


258     DISEASES  OF  .THE  PELVIC  CELLULAR  TISSUE. 

sacral  ligaments  at  the  sacrum.  The  most  frequent  site  for  cellulitis, 
■when  limited  in  extent,  is  under  the  posterior  face  of  the  broad  liga- 
ment in  close  proximity  to  the  cervix.  It  is  most  frequently  found 
in  the  left  broad  ligament,  or  extending  backward  along  the  right 
utero-sacral  ligament.  Whenever  a  prolapse  occurs,  or  a  retroversion, 
the  seat  of  greatest  irritation  must  be  near  the  attachment  of  the 
utero-sacral  ligaments  to  the  uterus,  where  the  weight  or  traction  is 
centralized.  In  case  of  injury  to  the  cervix  from  childbirth,  or  from 
any  surgical  procedure,  followed  by  inflammation,  cellulitis  readily 
occurs  between  the  folds  of  the  broad  ligaments.  This  is  easily  ex- 
plained from  the  fact  that  the  cellular  tissue  becomes  so  blended  with 
the  tissues  at  the  point  of  junction  of  the  cervix  and  vagina,  that  from 
the  contiguity  it  could  not  escape.  The  process  of  repair  is  usually 
more  active  in  the  cervix  than  it  is  in  the  neighboring  cellular  tissue, 
so  that  the  products  of  inflammation  are  likely  to  remain  long  after 
the  exciting  cause  has  disappeared.  It  may  then  require  but  a  slight 
provocation  to  light  up,  as  it  were,  into  a  flame,  a  condition  which,  in 
all  probability,  had  been  unsuspected. 

If  a  thickening  at  any  point  can  be  detected,  or  an  unusual  amount 
of  pain  be  elicited  from  pressure  of  the  finger,  the  prudent  operator 
will  recognize  its  full  import.  It  would  be  inadmissible,  under  such 
circumstances,  to  institute  any  surgical  procedure,  or  to  attempt  the 
replacing  of  the  uterus  if  it  be  retroverted,  to  introduce  the  sound,  or 
to  make  any  application  within  the  uterine  canal.  We  must  employ 
the  necessary  means  for  relieving  the  condition  of  the  circulation,  and 
by  having  the  case  under  observation,  the  proper  course  to  be  followed 
will  be  soon  plainly  indicated. 

Much  has  been  already  accomplished  by  different  observers,  but  I 
am  confident  that  the  greatest  advance  yet  to  be  made  in  this  branch 
of  surgery,  will  be  from  the  intimate  study  of  the  cellular,  or  connect- 
ive, tissue  of  the  pelvis.  We  will  there  find,  I  am  convinced,  the  key 
to  many  of  the  pathological  changes  now  treated  as  uterine  disease, 
and  it  will  be  shown  that  hitherto  we  have  confounded  cause  and  effect. 
I  have  long  sought  to  fully  solve  this  problem,  but  have  found  it  beyond 
the  scope  of  a  single  observer,  yet  I  may  be  the  means  of  pointing  out 
the  direction  in  Avhich  the  solution  lies.  Since  I  have  understood  the 
action  of  hot  tvater  vaginal  injections,  I  have  realized  that  this  remedy 
is  destined  to  overturn  both  the  theory  and  therapeutics  of  uterine 
disease,  as  now  accepted. 

Experience  teaches  that  hot  water  is  indispensable  in  the  treat- 
ment of  all  uterine  disease,  and,  since  it  only  affects  the  supposed  dis- 


CELLULITIS.  259 

ease  indirectly  after  giving  tone  to  the  bloodvessels  in  the  connective 
tissue  of  the  pelvis,  we  may  fairly  raise  the  question  as  to  the  original 
seat  of  disease. 

It  is  the  view,  generally  advanced  hy  the  writers  of  our  day,  that 
the  occurrence  of  cellulitis  is  secondary  to  some  exciting  cause  in  the 
uterus,  or  to  some  disease  in  the  Fallopian  tubes  or  in  the  ovaries.  It 
has  even  been  maintained  that  inflammation  could  not  have  a  begin- 
ning  in  the  cellular  tissue. 

jNIy  convictions  are  that  while  the  primary  cause  of  disease  lies, 
through  the  influence  of  the  sympathetic  system,  in  impaired  nutrition, 
we  must  look  to  pathological  changes  in  the  connective  tissue  as  the 
cause  of  the  results  we  now  regard  as  the  original  disease  in  the 
uterus  and  ovaries. 

These  views  have  no  reference  to  the  lesions  incident  to  the  puer- 
peral state,  for  there  I  recognize  that,  for  the  time  being,  the  uterus 
is  the  dominant  power.  Pathological  changes  are  then  brought  about 
in  the  connective  tissue  of  the  pelvis  as  secondary  to  the  uterine  con- 
dition, and  may  remain  long  after  the  original  causes  have  disappeared. 
But  these  pathological  changes  may  afterwards  so  far  affect  the  circu- 
lation, either  mechanically  or  through  the  nervous  system,  as  to  excite 
in  time  other  uterine  disease. 

In  no  other  portion  of  the  body,  within  the  same  extent  of  space, 
can  be  found  the  same  number  of  bloodvessels  or  nerves  as  are  dis- 
tributed to  the  pelvic  connective  tissue.  These  vessels  are  doubled 
upon  themselves  to  an  almost  incredible  degree,  so  that  they  cannot 
be  put  on  the  stretch,  or  their  calibre  lessened  by  the  traction  from 
pregnancy  or  uterine  displacement.  This  provision  is,  however,  a 
source  of  weakness,  should  local  nutrition  become  impaired,  since  a 
great  portion  of  the  blood  contained  in  a  woman's  body  may  become 
almost  stagnant  in  the  vessels  of  the  pelvis. 

We  are  told  that  cellulitis  is  generally  due  to  metritis  or  ovaritis. 
It  is  unquestionably  true  that  we  may  and  do  have  metritis  in  the 
puerperal  state  exciting  cellulitis,  but  I  deny  that  we  ever  have  in- 
flammation of  the  uterine  tissue  under  any  other  circumstances.  I 
have  never  found  pus  in  the  uterine  tissue,  nor  any  other  evidence  of 
inflammation  after  death,  in  any  form  of  uterine  disease,  except  in 
connection  with  childbirth  or  malignant  disease.  I  liave  never  seen 
a  case  of  ovaritis  without  inflammation  of  the  neighboring  tissues,  and 
where  I  have  had  the  opportunity  of  observing  one  early  enough,  I 
have  always  detected  the  cellulitis  before  the  ovary  became  involved. 
We  have  no  means  of  judging  with  any  accuracy  as  to  the  condition 


260  DISEASES    OF    THE    PELVIC    CELLULAR    TISSUE. 

of  the  Fallopian  tubes  during  life.  But  the  probabilities  are,  unless 
poisoned  in  the  first  instance  bj  some  foreign  irritant,  as  by  gonor- 
rhoea, that  inflammation  of  its  mucous  membrane,  with  that  of  the 
uterus,  is  secondary  to  some  previous  lesion  in  the  cellular  tissue. 
This  vieAV  is  not  an  irrational  one,  since,  if  the  uterus  is  not  impreg- 
nated, for  equal  extent  of  space,  the  cellular  tissue  is  much  more 
abudantly  supplied  with  bloodvessels  and  nerves  than  is  the  uterus. 
The  uterus  is  entirely  dependent  on  the  blood,  which  is  first  distributed 
through  the  connective  tissue,  and  its  nerve-fibres  reach  the  organ 
by  the  same  route.  I  hold  that  the  cellular  tissue  is  the  first  and  most 
exposed  to  influences  exerted  through  the  bloodvessels,  and  conse- 
quently it  is  the  more  liable  to  become  inflamed,  just  as,  for  instance, 
he  who  transports  nitro-glycerine  is  more  exposed  to  danger  than  he 
to  whom  it  is  to  be  delivered. 

To  illustrate  :  the  circulation  in  a  portion  of  the  cellular  tissue  may 
become  obstructed  from  some  cause,  Avith  the  efi"ect  of  producing  con- 
gestive hypertrophy  of  the  uterus  from  partial  stagnation.  One  of 
the  first  efforts  of  nature  Avould  be  to  temporarily  relieve  this  condi- 
tion by  an  increase  of  secretion  from  the  mucous  follicles.  As  this 
discharge  continued  to  flow  over  a  surface,  the  epithelium  would  at 
length  be  lost,  and  what  has  hitherto  been  termed  ulceration  would  be 
produced.  It  has  been  the  accepted  practice,  even  to  the  present 
time,  of  applying  caustic  remedies  to  such  a  surface  until  the  char- 
acter of  the  tissue  became  destroyed,  when,  of  course,  the  discharge 
would  cease,  with  the  original  condition,  however,  remaining  un- 
changed. I  hold  it  to  be  more  rational  to  restore  first  the  circulation 
in  the  cellular  tissue,  after  Avhich  the  hypertrophy  of  the  uterus  will 
rapidly  diminish,  the  discharge  will  cease,  and  the  so-called  "  ulcera- 
tion" heal  Avithout  further  care. 

An  elaboration  of  these  vieAvs  might  have  been  more  in  place  while 
considering  the  general  principles,  but  they  have  been  presented 
intentionally  in  the  present  connection,  that  they  may  be  the  more 
forcibly  impressed.  Injuries  of  the  pelvic  cellular  tissue  will  be 
treated  of  under  the  heads  of  cellulitis,  pelvic  abscesses,  and  hema- 
tocele. 

Etiology  of  Cellulitis. 

The  causes  of  inflammation  of  the  cellular  or  connective  tissue  of 
the  pelvis  may  be  classed  as  puerperal  and  accidental. 

It  may  be  claimed  that  many  of  the  injuries  of  childbirth  arc  acci- 
dental, and,  to  a  certain  extent,  this  is  true,  so  far,  at  least,  as  regards 


ETIOLOGY.  261 

the  exciting  cause.  But  the  puerperal  state  is  one  in  which  the  con- 
nective tissue  is  not  only  liable  to  injurj  from  pressure  and  from  lace- 
ration, but  to  inflammation  extending  from  the  veins  of  the  uterus  to 
those  in  the  connective  tissue.  From  the  great  increase  in  vascularity 
of  the  parts,  the  woman  is  then  the  more  liable  to,  and  the  less  able 
to  resist,  the  effects  of  local  injury,  which,  in  the  non-puerperal  state, 
would  be  productive  of  but  little  disturbance. 

I  am  deeply  impressed  with  the  belief  that  future  observation  will 
establish  the  fact  that  phlebitis  is  a  common  factor  in  pelvic  cellular 
inflammation.  We  have  yet  to  learn  the  determining  element  which 
in  one  instance  will  cause  phlebitis,  and  in  another,  inflammation  of 
the  cellular  tissue  itself.  The  connective  tissue,  of  course,  becomes 
more  or  less  involved  Avith  phlebitis,  but  the  extent  of  inflammation  in 
the  other  condition  is  more  decided,  and  is  accompanied  by  intense 
arterial  congestion.  That  phlebitis,  in  the  pelvic  cellular  tissue  does 
exist  in  connection  with  the  puerperal  state,  as  taught  by  Trousseau,  I 
have  verified  in  early  life,  when  my  opportunities  were  better  for 
studying  these  pathological  changes  ;  but  it  must  be  left  to  future 
observation  to  determine  how  it  occurs  in  the  non-puerperal  condition, 
for  I  have  had  no  opportunity  of  establishing  this  point. 

But  a  very  moderate  amount  of  experience  would  be  sufficient  to 
impress  any  observer  with  a  belief  in  the  existence  of  a  marked  differ- 
ence in  the  forms  of  cellulitis,  a  difference  which  cannot  be  dependent 
on  either  locality  or  changes  in  the  general  condition.  A  most  ex- 
tensive phlegmonous  cellulitis  may  be  detected  after  childbirth,  which 
will  sometimes  rapidly  disappear  within  the  course  of  a  few  days, 
and  we  frequently  meet  with  like  cases  in  the  non-puerperal  state. 
On  the  other  hand,  a  less  extended  inflammation,  following  a  lacerated 
cervix,  for  instance,  may  last  for  years,  and  we  may  find  exactly  the 
same  condition  and  result  after  exposure  to  cold.  It  is  in  conse- 
quence of  these  great  differences  that  I  am  impressed  with  the  belief 
that  the  immediate  exciting  causes  of  the  inflammation  cannot  be  the 
same  under  all  circumstances.  We  may  have  the  most  extensive 
inflammation  rapidly  disappearing,  coincident  with,  or  as  consequent 
upon,  a  certain  course  of  treatment.  Yet,  in  a  similar  case,  or  with 
the  patient  in  even  better  general  health,  the  local  condition  will 
remain  for  months  or  years  unchanged.  We  have  yet  to  ascertain 
what  the  predisposing  condition  is,  since  the  most  insignificant  exciting 
cause  may,  in  some  instances,  be  followed  by  the  most  disastrous 
results,  and  in  others  be  absolutely  Avithout  bad  effects.  A  low  grade 
of  phthisis,  it  is  believed,  may  remain  for  an  indefinite  period,  and 


262     DISEASES  OF  THE  PELVIC  CELLULAR  TISSUE. 

its  existence  in  the  cellular  tissue  is  the  most  rational  explanation 
■which  can  be  offered  for  the  occurrence  of  these  sudden  complications. 

We  shall  consider  briefly  the  statistical  history  of  some  three 
hundred  and  three  cases  of  cellulitis  treated  in  my  private  hospital. 

The  average  age  of  puberty  was  14.02  years,  and  that  of  marriage, 
for  the  fruitful  women,  was  19.84,  and  they  are  both  almost  identically 
the  same  as  was  obtained  for  the  general  averages.  But  the  average 
age  of  marriage  for  the  sterile  women  was  22.88  years,  which  is 
nearly  three  years  later  in  life  than  the  general  average  on  all  women. 
The  average  number  of  children  was  but  1.86,  and,  including  the 
miscarriages,  we  have  but  an  average  of  2.15  pregnancies  for  each 
woman.  Both  of  these  averages  are  much  below  those  obtained  on 
the  total  number  of  all  women  under  observation.  This  is  certainly 
an  indication  of  the  fact  that  cellulitis  is  a  cause  of  sterility,  and  this 
is  corroborated  by  the  average  length  of  time  since  the  last  pregnancy, 
which  was  found  to  have  been  6.69  years.  The  average  age  at  the 
time  of  the  first  consultation  was  29.44  years  for  the  fruitful,  81.43 
years  for  the  sterile,  and  27.88  years  for  the  unmarried  women.  This 
would  show  that  the  average  age  for  the  fruitful,  at  the  termination 
of  the  last  pregnancy,  was  22.75  years. 

Of  the  total  number  of  cases  of  cellulitis  under  observation,  157, 
or  51.81  per  cent.,  had  no  uterine  or  ovarian  disease  which  could  be 
detected.  If  any  form  of  these  diseases  had  been  the  exciting  cause 
of  the  cellulitis,  all  traces  had  disappeared,  so  as  to  leave  only  the 
product.  The  remaining  156  cases  suffered  from  other  lesions  in 
addition  to  the  cellulitis.  The  supposed  causes  of  the  cellulitis  will 
be  given  as  reported  by  those  patients  where  no  uterine  disease  could 
be  detected  when  first  examined. 

The  first  feature  presenting  itself  in  Table  XI Y.,  in  regard  to  the 
liability  to  the  disease,  is  that  the  proportion  of  unmarried  and  sterile 
women  is  greater,  and  that  of  the  fruitful  women  is  nearly  fourteen 
per  cent,  less  than  the  general  average  for  all  women  under  observa- 
tion. The  greater  number  of  the  unmarried  women  traced  their 
diseases  to  exposure  and  imprudence  in  dress,  and  the  proportion  I 
do  not  believe  is  over-estimated.  Almost  as  large  a  percentage  of 
sterile  Avomen  attributed  their  bad  health  to  the  marriage  state,  in 
other  words  they  suffered  the  penalty  for  violating,  in  some  manner, 
the  laws  of  nature.  Nearly  all  the  fruitful  women  had  suffered  since 
the  termination  of  pregnancy.  It  is  a  melancholy  fact,  as  shown, 
that  of  forty-six  women  who  suffered  from  cellulitis,  and  could  assign 
a  cause,  over  twenty-three  per  cent,  acknowledged  to  have  undergone 


CAUSES    OF    CELLULITIS. 


2G3 


criminal  abortion.  This  percentage,  I  believe,  would  be  much  under 
the  actual  proportion  were  we  able  to  designate  the  "  unknown  causes." 
The  same  would  be  applicable  to  the  sterile  women,  in  so  many  of 
wliom  cellulitis  was  excited  in  consequence  of  their  having  employed 
some  means  to  prevent  conception.  To  the  use  of  the  sewing  machine, 
as  one  of  the  causes,  I  am  satisfied  too  small  a  proportion  has  been 
attributed.  This  instrument  is  in  such  general  use,  and  so  little 
regard  is  paid  to  the  importance  of  not  using  it  during  the  menstrual 
period,  that  we  cannot  over-estimate  its  injurious  efiects.  It  should 
be  used  with  the  greatest  judgment  by  the  most  robust  women,  while, 
for  the  delicate  no  more  certain  means  could  be  devised  for  producing 
disease. 


Table  XIY — Supposed  Causes  of  Celhditis,  uncomplicated  with  other 

local  disease. 


Causes. 

Unmarried. 

Sterile. 

Fruitful. 

Total.       Percentage. 

Married  life     .     . 
Childbirth .      .      . 
Miscarriage 
Criminal  abortion 
Exposure  to  cold . 
Excessive  study  , 
Falling  down  stairs 
Sewing  machine  . 
Sudden  fright 
Unknown  causes  . 

"ii" 

1 
5 
1 
1 
17 

14 

'"e" 

1 
1 
1 
1 
30 

"21'" 
11 
11 

2 
'"{" 

21 

14 

21 

11 

11 

19 

2 

7 

2 

2 

68 

8.91 

13.37 

7.00 

7.00 

11.79 

1.21 

4.45 

1.21 

1.21 

43.64 

Total 

Percentage    . 

36 

22.93 

54 
34.39 

67 
42.67 

157 

51.81 

Another  factor  in  causing  cellulitis,  viz.,  that  of  rupture  of  blood- 
vessels, does  not  appear  in  the  record,  since  the  patient  would  be 
ignorant  of  the  occurrence.  Yet,  a  very  superficial  study  of  the 
circulation  through  the  pelvis,  even  in  health,  would  be  sufficient  to 
convince  any  one  that  this  accident  cannot  be  a  rare  one.  Extra- 
uterine pregnancy,  rupture  of  cysts,  and  the  escape  of  any  foreign 
body  into  the  peritoneal  cavity,  are  all  capable  of  producing  pelvic 
peritonitis  and  general  cellulitis.  But  this  has  been  already  referred 
to  in  the  chapter  on  hematocele. 

In  Table  XV.  are  presented  the  diflFerent  diseases  which  were  found 
in  complication  with  cellulitis.  Displacements  of  the  uterus  form  over 
fifty-four  per  cent,  of  the  lesions  found  to  be  accompanied  with  cellu- 
litis.    The  next  most  important  accompaniment  was  laceration  of  the 


264 


DISEASES    OF    THE    PELVIC    CELLULAR    TISSUE. 


cervix,  which,  by  extending  into  the  connective  tissue  of  the  pelvis 
during  childbirth,  readily  produced  cellulitis.  The  result  was  one 
which  often  follows  laceration,  the  patient  being  liable  for  a  long  time 
after  the  reception  of  the  injury  to  fresh  attacks  of  cellulitis,  which 
may  come  on  from  the  slightest  provocation.  The  product  of  this 
inflammation,  or  the  condition  remaining  after  an  attack,  is  generally 
situated  in  the  broad  ligament,  on  the  same  side  on  which  the  lacera- 
tion occurred  through  the  cervix.  Its  presence  there  is  seldom  recog- 
nized, in  consequence  of  an  incomplete  examination.  It  is  to  be  noted, 
also,  that  it  may  be  readily  set  up  by  an  unskillful  examination,  by 
dragging  down  the  uterus,  or  on  using  any  other  undue  violence. 


Table  XV Different  Diseases  in  Complication  with  Cellulitis. 


CeUulitis  with  other  diseases.        Unmarried.       Sterile.        Fruitful.        Total.       Percentage 


Versions 

Flexures 

Laceration  of  the  cervix 

Fibroids 

Hsematocele  .... 
Early  atrophy  of  the  uterus 
Prolapse  of  the  ovary  . 
Contraction  of  the  os  uteri 
Ovarian  tumor  . 
Fibrous  tumor 

Fibro-cyst 

Rectocele 

Procidentia      .... 
Lacer'n  of  the  sphincter  ani 

Cystitis 

Change  of  life  .... 


Total  .     . 
Percentage 


14 
9-58 


17 

20 


51 
34-93 


25 

10 
2(3 
11 


81 
55.02 


45 
32 
26 
IG 
5 
5 
4 
3 
2 
2 
1 
1 
1 
1 
1 
1 


146 
48.1? 


30.82 

22.59 

17.80 

10.96 

3.42 

3.42 

2.73 

2.05 

1.36 

1.36 

.68 

.68 

.68 

.68 

.68 

.68 


By  Table  XVI.  is  shown  the  relative  frequency  of  location  of  the 
cellulitis,  with  the  changes  in  the  length  and  quantity  of  the  menstrual 
flow.  The  record  is  perfect  so  far  as  relates  to  the  cases  of  luicom- 
plicated  cellulitis,  but  the  location  was  not  noted  where  the  disease 
was  associated  with  other  lesions.  The  more  frequent  occurrence  of 
cellulitis  on  the  left  side  is  particularly  remarkable.  Of  one  hundred 
and  fifty-seven  cases  of  uncomplicated  cellulitis,  forty-one  per  cent, 
occurred  oh  the  left  side,  and  only  ten  per  cent,  on  the  right  side. 
General  cellulitis  was  next  in  fro(i[uency  of  occurrence ;  then,  in  order, 
followed  inflammation  behind  the  uterus,  and  lastly,  on  the  right  side, 
and  pelvic  abscesses,  which  were  found  to  be  of  the  same  relative 


MENSTRUATION    AS    AFFECTED    BY    CELLULITIS, 


265 


►<  ? 


<l      "2 


•IBJOJ, 


•aiHoJS 


■8l3uig 


•injijnjji 


•8[3nig 


•oiSuig 


«         ei         N         r-c 


i-i         c^ 


•luao  I8j; 

to 
o 

to 
to 

CO 

Ti; 

•aaqninjj 

12 

2 

<M 

(^ 

Cl 

<  '■ — 


o  a 

Fa. 


•8IU8JS 


•aiSnig 


■aiSnig 


"injJuiJi 


i-J  r-  Cl 


r-  rH  'J' 


r-<  CI  <N 


o  ^  _  J 

B  O  a 
O  „  - 


P^O 


•I'EJOJ, 


•inj^mjj: 


•eiuais 
•aX^TXig 


o         

^  'aX^nig 


•axuaig 
■axSnig 


-l"         r-l  >3         i-<  (M 


r-f         CO         CO 


C         eJ        ^ 


—  —   ^  g 


266 


DISEASES    OF    THE    PELVIC    CELLULAR    TISSUE. 


Ill 


uaqumji 


O        I^-        O        05        N 


CO         ^^         O         CO         t^ 

CO         (M         to         r-.         1-1 


•}ua3  .I9J^ 


•^U.O  idj_ 


IM  rl  CO 


CO        -1^        CO        o 


^ 

^^ 

o 

!0 

to 

o 

to 

o 

,-H 

""■ 

lO 

'-' 

cc 

o: 

-5t< 

to 

■o 

^ 

tl 

^ 

ir^ 

t—i 

t^ 

,—, 

OO 

?T 

(M 

CO 

^ 

■^ 

-H  to  i-H 


tS  O 

C3  3^ 

O  >| 

o  O^ 

5  ~ 


•aiijaig 


•aiSaig 


C)         1-1  .         (M 


IM         rH         i-( 


•jnaa  J8  j; 


•injnti-il 


•exijajS 


•aiSni.s 


Oi        *^        CO        -"        t« 
C^         CO         1—1         CO         CO 


00         ■*         C-3         --^         CO 


•i"jn"->j. 


•an.ia^g 


■^iSnig 


IC        CO        CO 


•  ^  1 

:  t^      "o 


c  o 


t- 

fin 

^. 

' 

tf,       J3 

=  T.^S 

5  St35 

fll 

-    O    CU    o 

DU 

MENSTRUATION    AFTER    CELLULITIS. 


207 


frequency.  There  is  little  to  be  noted  as  to  the  relative  frequency  of 
cellulitis  in  any  special  locality,  according  to  the  conditions  of  life, 
unless  the  result  of  accident.  But  under  the  head  of  pelvic  abscess 
we  find  that  of  seventeen  cases  only  one  occurred  among  the  unmar- 
ried, a  proportion  too  small  to  have  been  accidental. 

For  the  purpose  of  showing  the  changes  in  menstruation,  the  usual 
form  has  been  followed  in  the  table.  Two  divisions  are  first  made, 
showing  that  one  hundred  and  eighty -nine  cases  remained,  after  the 
cellulitis,  unchanged  as  to  the  length  of  the  flow.  With  ninety-nine 
cases,  forming  the  second  group,  both  time  and  quantity  became 
changed.  Eighty-four  of  those  forming  the  first  division,  represent- 
ing 29.16  per  cent,  of  the  total,  underwent  no  change  either  as  to 
time  or  quantity.  The  menstrual  flow  remained  the  same  as  it  was 
before  the  attack  of  cellulitis,  whether  normal,  too  free,  or  scanty. 
We  must,  however,  acknowledge  our  ignorance  of  the  causes  which, 
under  apparently  similar  circumstances,  determine  changes  in  the 
quantity  of  the  menstrual  flow  after  an  attack  of  cellulitis.  Whatever 
these  are,  it  is  manifest,  from  the  remarkable  uniformity  in  the  per- 
centages, Avhether  taken  on  the  uncomplicated  or  complicated  cases, 
that  they  are  influenced  by  the  character  of  the  cellulitis. 


Table  XVII Condition  of  the  Menstrual  Flow  after  Cellulitis. 


Conrlition  of  the  menstrual 
flow  alter  cellulitis. 

Uncompllcate  I.       j         Complicated. 

Total. 

Cases. 

Per  cent. 

Cases. 

Per  cent. 

Cases. 

Per  ceot. 

Normal 

Too  free,  or  increased 

Scanty    

Lessened      .... 
Irregular      .... 

24 
48 
11 
46 

18 

16.32 
32.64 
7.48 
31.29 
12.24 

30 

52 

8 

41 

10 

21.27 
36.87 

5.67 
29.07 

7.09 

54 

100 

19 

87 
28 

18.75 

34.72 

6.59 

30.20 

9.92 

Total  .... 

147 

....      '     141 

1 

288 

A  glance  at  Table  XVII.  will  show  the  menstrual  changes  in 
quantity,  without  regard  to  the  length  of  the  flow.  A  comparison 
is  given,  at  the  same  time,  as  to  the  relative  frequency  of  these 
changes  between  the  uncomplicated  cases  of  cellulitis  and  those  which 
were  complicated  with  other  diseases.  It  is  shown  that  the  quantity 
remained  normal  with  18.75  per  cent.,  while  the  flow  in  a  larger 
proportion  of  cases  (but  in  nearly  equal  numbers),  in  comparison 
with  each  other,  became  either  increased  or  lessened.     The  apparent 


268  DISEASES    OF    THE    PELVIC    CELLULAR    TISSUE. 

discrepancy  between  the  total  numbers,  as  shown  in  Tables  III.  and 
IV.,  is  due  to  the  fact  that,  in  the  latter,  fifteen  cases  of  cellulitis, 
occurring  after  the  change  of  life,  are  not  included. 

As  a  proof  of  the  assertion  that  cellulitis  was  due  to  uterine  or 
ovarian  disease  existing  during  the  menstrual  life,  it  has  been  held 
by  different  authorities  that  it  does  not  occur  after  the  change  of  life. 
I  have,  in  consultation,  met  with  two  cases  of  cellulitis  in  the  child 
between  eight  and  ten  years  of  age,  and  before  any  evidence  of 
approaching  puberty  existed.  My  private  hospital  records  show  that 
I  have  had  under  my  care  fifteen  cases  of  cellulitis  occurring  after 
the  change  of  life.  All  of  these  were  between  forty-five  and  fifty -five 
years  of  age  ;  in  one  of  them  the  menstrual  flow  had  ceased  eleven 
months  previous  to  the  attack,  and  in  another,  an  interval  of  seven 
years  had  elapsed.  The  number  of  cases  I  have  given  constitute 
about  five  per  cent,  on  the  total  of  all  cases  of  cellulitis  passing  under 
my  observation.  The  lesion  is,  beyond  question,  a  rare  one  after  the 
change  of  life,  in  consequence  of  the  difference  in  the  character  of 
the  tissues,  and  because  the  quantity  of  blood  going  to  the  parts  then 
becomes  reduced  to  just  what  is  necessary  for  nutrition.  But  there  is 
certainly  no  ground  on  which  to  base  a  theory  of  immunity  after  the 
menopause,  since  every  portion  of  the  human  body  may,  under  favor- 
able circumstances,  become  inflamed.  Two  of  these  cases  I  treated 
for  pelvic  abscess ;  one  had  previously  suffered  for  several  years  from 
senile  vaginitis,  and  the  other  had  married  a  second  time,  and  late  in 
life,  a  man  much  younger  than  herself.  These  patients  were  unable 
to  give  any  explanation  for  the  cellulitis,  but  I  noted  these  circum- 
stances at  the  time,  as  indicating,  in  all  probability,  the  exciting 
causes. 

Symptoms  of  Pelvic  Cellulitis. — An  attack  of  cellulitis  is  generally 
ushered  in  by  a  chill  of  more  or  less  severity,  followed  by  fever. 
But,  at  times,  the  attack  begins  with  pain  and  fever  without  any 
perceptible  chill.  Again,  extensive  cellulitis  is  occasionally  detected 
by  accident,  after  having  become  already  well  advanced  without 
causing  any  particular  disturbance.  Fever  and  pain  about  the  lower 
portion  of  the  abdomen  are,  however,  the  usual  symptoms.  The 
pulse  Avill  become  greatly  increased  in  rapidity,  and  the  thermom- 
eter, if  placed  in  either  the  axilla  or  mouth,  will  indicate  a  marked 
elevation  in  temperature.  As  the  temperature  is  usually  at  least  one 
deicrce  his-her  in  the  vaj!:ina,  during  an  attack  of  local  inflammation,  it 
is  better  for  the  sake  of  greater  accuracy  to  make  the  observation  in 
the  vagina.     Unless  the  inflammation  be  very  extensive,  so  as  to  in- 


SYMPTOMS    OF    CELLULITIS.  2G9 

volve  the  peritoneum,  the  symptoms  are  not  always  -well  marked,  nor 
do  they  follow  closely  any  rule. 

If  the  attack  be  a  severe  one,  there  will  be  tenderness  over  the 
lower  portion  of  the  abdomen  to  either  side,  or  over  the  whole  surface. 
The  abdomen  will  be  found  tympanitic  and  intolerant  to  pressure, 
while  the  patient  w^rll  lie  on  the  back  with  the  knees  w^ell  drawn  up, 
and  unable  to  extend  them  without  increasing  the  pain.  These  symp- 
toms are  found  accompanying  an  attack  of  hysteria,  and  this  distur- 
bance of  the  nervous  system  may  even  be  an  additional  complication 
with  the  cellulitis.  But  the  elevation  of  temperature,  as  indicated 
by  the  thermometer,  is  an  important  diagnostic  sign,  since  there  is 
no  such  change  in  hysteria. 

Nausea  may  exist  early  in  the  disease,  but  vomiting,  with  the  ejection 
of  bile  in  large  quantities,  indicates  a  serious  extent  of  the  disease, 
"with  general  peritonitis.  As  the  cellulitis  becomes  overshadowed  by 
the  extension  of  the  peritonitis,  the  extent  of  the  latter  will  be  indica- 
ted by  the  expression  of  the  patient's  face,  and  by  the  tone  of  her 
voice.  The  features  will  become  more  pinched,  and  the  voice  will 
resemble  closely  that  characteristic  of  the  collapse  of  cholera.  When 
the  peritonitis  has  been  unusually  rapid  in  its  progress,  it  seems  to 
sear  its  Avay  as  "with  the  white  heat  of  a  cautery,  and  to  destroy  sensa- 
tion. I  have  seen  such  inflammations  begin  as  a  cellulitis,  extend  to 
the  peritoneum,  and,  becoming  general,  run  their  course  in  a  few  hours, 
"without  the  slightest  local  suffering  or  even  pain  on  pressure.  From 
the  shock  and  rapid  depression  to  the  life  force,  the  temperature  -will 
fall  even  below  the  normal  standard,  while  the  pulse  -will  rapidly  in- 
crease, since  the  heart,  from  a  loss  of  power,  is  now  obliged  to  make 
a  greater  number  of  contractions.  That  the  temperature  should  go 
down  as  the  pulse  increased  in  frequency  is  apparently  an  anomaly. 
The  rule  is,  hoAvever,  as  applicable  to  all  conditions  of  rapidly  failing 
power.  The  explanation  lies,  at  the  beginning,  in  imperfect  aeration 
of  the  blood  in  the  lungs,  from  which  the  capillary  circulation  becomes 
diminished  in  proportion  as  the  needed  stimulus  of  oxygen  is  deficient. 
A  depression  in  temperature  on  the  surface  would  naturally  follow, 
while  the  heart,  although  enfeebled,  must  increase  its  frequency  of 
action  to  get  rid  of  the  accumulation  of  blood.  Experience  has  taught 
me  that,  in  any  acute  disorder,  it  is  the  beginning  of  death  when  the 
temperature  of  the  body  falls  below  a  point  which  is  disproportionate 
to  the  extent  of  the  disease,  the  pulse,  at  the  same  time,  becoming 
rapid  and  equally  out  of  proportion.  In  such  cases  of  peritonitis  this 
is  an  infallible  indication  of  the  beginning  of  the  end,  notwithstandins: 


270  DISEASES    OF    THE    PELVIC    CELLULAR    TISSUE. 

the  strength  of  the  patient  may  yet  seem  fair,  and  other  grave  symp- 
toms be  absent. 

In  other  cases,  after  a  certain  interval,  there  will  be  a  remission  of 
fever,  but  never  a  marked  intermission  until  the  commencement  of 
resolution  or  convalesence.  The  pyrexia  will  continue  above  the 
normal  point  in  the  vagina,  although  the  heat  of  the  skin  may  seem 
natural,  while,  towards  the  close  of  the  day,  there  will  always  be  a 
perceptible  rise  in  the  general  temperature.  The  symptoms  will  all 
be  marked  just  in  proportion  to  the  extent  of  the  peritoneum  involved, 
and,  in  extreme  cases,  the  pelvic  condition  may  be  masked  entirely 
by  the  symptoms  of  general  peritonitis.  In  fact,  without  the  aid  of  a 
digital  examination,  the  extent  of  the  cellulitis  would  remain  unknown. 

The  first  shock  of  the  disease  is  spent  on  the  nervous  system, 
whether  the  exciting  cause  be  blood-poisoning,  extension  of  the  inflam- 
mation over  a  greater  area,  or  the  sudden  occurrence  of  cellulitis  itself. 
We  can  only  recognize  the  result  of  the  shock  by  the  chill,  during  Avhich 
the  blood  flows  from  the  surface  to  the  internal  organs,  producing  in- 
tense pelvic  congestion.  Nature's  first  effort  to  relieve  this  will  be  by 
the  escape  of  the  watery  portions  of  the  blood  through  the  coats  of 
these  vessels,  so  that  the  tissues  become  infiltrated  with  serum.  Then 
reaction  comes  on,  by  which  the  circulation  is  partially  restored,  and 
the  fever  correspondingly  subsides.  If  the  finger  be  now  introduced 
into  the  vagina,  no  hardening  of  the  tissues  can  yet  be  detected,  but 
the  sensation  of  a  fulness  and  a  baggy  feeling  will  be  appreciated, 
and  there  will  be  a  marked  elevation  of  temperature. 

As  the  disease  advances,  so  as  to  involve  the  peritoneum,  the  uterus 
becomes  fixed  in  its  position,  and  the  roof  of  the  pelvis  tightened,  as 
I  have  described.  With  this  process,  plastic  lymph  is  thrown  out, 
opposing  sides  of  the  peritoneum  adhere  and  inclose  the  inflammatory 
products.  Then  the  finger  in  the  vagina  will  be  able  to  detect  rough- 
ened surfaces,  as  if  hard  masses  of  some  foreign  substance  had  become 
inclosed  within  the  pelvic  tissues. 

When  reaction  occurs,  if  the  circumstances  are  favorable,  the 
oedema  of  the  tissues  rapidly  disappears,  and  these  hard  masses  melt 
away,  as  it  were.  The  uterus  soon  becomes  again  movable,  and  the 
only  product  of  the  inflammation  remaining  afterwards  will  be  a  band 
formed  from  the  shrinkage  of  the  tissues  which  had  been  involved. 
Should  the  uterus  or  the  intestines  be  bound  down  by  adhesions,  the 
former  can  be  relieved  and  replaced  by  art,  while  the  peristaltic 
action  will  in  time  liberate  the  latter.  But  the  damage  Avill  be  almost 
irreparable  whenever  the  ovaries  have  been  involved,  or  the  broad 


SYMPTOMS    OF    CELLULITIS.  271 

ligaments,  if  of  sufficient  extent  to  include  the  Fallopian  tubes.  As 
the  ovaries  are  stationary,  they  will  remain  buried  in  the  lymph, 
which  has  been  thrown  out,  and  they  may  become  atrophied.  By 
contraction  of  these  bands,  the  needed  supply  of  blood  becomes  cut 
off,  and  atrophy  must  follow.  Nerve  filaments  are  often  involved  in 
the  mass  and  are  compressed  by  contraction,  with  the  effect  of  causing 
ovarian  neuralgia  or  reflex  irritation  elsewhere.  To  attacks  of  cellu- 
litis, wdiich  may  have  produced  but  little  disturbance  at  the  time,  can 
be  traced  the  chief  causes  of  sterility.  The  ovary  may  become  • 
covered  in  by  a  mass  of  lymph,  as  has  been  stated,  so  that  the  ova 
cannot  escape  from  the  Graafian  follicles.  The  fimbriated  extremity 
of  the  Fallopian  tube  may  have  been  bound  down  or  so  displaced  by 
adhesion,  as  to  be  no  longer  able  to  grasp  the  ovary  for  the  purpose 
of  receiving  the  ovum  as  it  escapes  from  the  ovarian  stroma.  Or, 
some  portion  of  the  Fallopian  tube  may  become  obliterated  by  a  band 
of  adhesion.  Moreover,  these  consequences  are  by  no  means  de- 
pendent upon  the  apparent  gravity  of  the  attack. 

After  subsidence  of  the  attack,  if  nature,  alone  or  aided  by  art, 
be  unable  to  remove  the  products  of  the  inflammation,  symptoms  of 
blood-poisoning  present  themselves,  in  consequence  of  the  absorption 
of  septic  material  into  the  general  circulation,  as  if  it  were  nature's 
last  eflFort  to  restore  the  integrity  of  the  parts.  The  patient  now 
suff"ers  from  rigors,  followed  by  fever,  and  with  but  a  slight  remis- 
sion of  these  symptoms  at  any  time  in  the  day.  The  encysted  lymph 
and  serum  break  down  into  pus,  wdiich,  infiltrating  the  neighbor- 
ing tissues,  acts  as  a  foreign  substance,  and  sets  up  a  fresh  inflamma- 
tion, causing  their  degeneration.  A  number  of  small  accumulations 
of  pus  thus  formed,  at  length  coalesce  into  one  or  more  large  ab- 
scesses. These  accumulations  of  pus  extend  in  the  direction  pre- 
senting the  least  resistance,  and  generally  empty  themselves  unaided. 
The  most  frequent  point  of  escape  is  into  the  posterior  cul-de-sac  of 
the  vagina,  or,  if  from  either  broad  ligament,  a  little  to  one  side  and 
posterior  to  the  cervix.  These  abscesses  rupture  almost  as  often  into 
the  rectum,  and  with  less  frequency  into  the  bladder.  Occasionally 
the  contents  of  an  abscess  may  escape  into  the  small  intestines,  in 
consequence  of  some  adhesion,  or  it  may  follow  the  course  of  the  psoas 
muscle,  and  open  at  the  groin.  It  is  the  least  likely  to  rupture  into 
the  peritoneal  cavity,  since  it  requires  so  little  irritation  to  produce 
adhesive  inflammation  of  this  membrane  that  it  would  be  protected  in 
advance.  Should  this  accident  occur,  the  shock  would  be  necessarily 
great,  fresh  inflammation  would  be   excited,  and  there  could  be  no 


272  DISEASES    OF    THE    PELVIC    CELLULAR    TISSUE. 

safety  for  the  patient  unless  it  proved  the  means  by  which  the  pus 
could  again  become  encysted. 

In  rare  instances,  the  pus  may  pass  from  the  pelvis  through  either 
sciatic  foramen,  and  burroAV  under  the  glutei  muscles,  or  in  the  neigh- 
borhood of  the  hip-joint.  In  many  instances  the  escape  of  pus  will 
continue  only  for  a  limited  time,  and,  as  the  point  of  rupture  is  gene- 
rally at  the  most  dependent  portion,  the  abscess  is  kept  empty,  its 
cavity  shrinks,  the  walls  adhere,  and  the  discharge  gradually  ceases. 
The  symptoms  of  blood  poisoning  rapidly  disappear,  and  the  restora- 
tion to  health  is  unobstructed. 

Under  other  circumstances,  the  hectic  fever  and  blood-poisoning 
increase,  and  the  discharge  becomes  more  abundant.  This  occurs 
when  the  walls  of  the  abscess  happen  to  be  so  thick  that  they  cannot 
be  brought  into  contact,  or  when  its  cavity  cannot  be  reduced  after 
the  escape  of  its  contents.  The  whole  interior  then  becomes  a  pus- 
secreting  surface,  and  the  disease  proves  a  serious  hindrance  to  the 
recuperative  powers.  Under  no  other  circumstances  does  a  woman 
show  to  greater  advantage  her  natural  tenacity  of  life  and  powers  of 
endurance.  I  have  seen  this  drain  kept  up  for  two  years,  and  with  a 
degree  of  hectic  and  emaciation  unequalled  in  the  course  of  any  other 
disease,  and  yet  recovery  took  place. 

I  have  met  with  several  instances  where  a  collection  of  pus  had 
become  sacculated,  and,  without  producing  any  constitutional  disturb- 
ance, had  remained  in  this  condition  for  years,  as  I  had  every  reason 
to  believe  from  the  history  of  the  cases.  An  accumulation  of  pus  in 
the  neighborhood  of  the  uterus,  with  thickened  inflamed  tissues  about 
it,  has  been  frequently  mistaken  for  a  fibroid  with  a  supposed  recent 
attack  of  cellulitis. 

The  following  history  of  a  case*  is  of  interest  in  this  connection. 

Case  XV. — Mrs.  E.  K.,  aged  twenty-nine,  was  admitted  to  the 
Woman's  Hospital  Nov.  9,  1868.  She  had  given  birth  to  her  first 
child,  without  complication,  and  remained  in  good  health  until  some 
five  years  previous  to  admission,  when  she  was  delivered  of  twins  by 
a  somewhat  tedious  but  otherwise  natural  labor.  Shortly  afterwards 
she  consulted  an  eminent  physician  of  New  York,  for  the  relief  of  a 
feeling  of  discomfort  experienced  whenever  she  assumed  the  upright 
position.  Her  difficulty  was  recognized  as  due  to  the  existence  of  a 
fibrous  tumor  on  the  posterior  wall  of  the  uterus,  and  to  its  presence 
was  attributed  her  previous  tedious  labor.  Some  two  years  afterwards 
she  gave  birth  to  her  last  child  by  a  natural  although  equally  tedious 

'  "A  Case  of  Faulty  Diagnosis,"  etc.,  presented  at  the  meeting  of  the  State 
Medical  Society,  1809,  and  i)ublislied  in  the  N.  Y.  Medical  Record,  Feb.  1,  18(j!). 


PELVIC    ABSCESS.  273 

labor.  Her  recovery  was  slow,  and  she  was  confined  to  her  bed  for 
six  weeks  before  she  regained  her  strength.  On  resuming  her  honse- 
hold  duties  she  became  consciovis  that  her  local  difficulties  had  in- 
creased. For  the  first  time  she  suffered  from  a  continued  irritation  of 
the  bhadder,  aggravated  whenever  she  stood  on  her  feet.  Three  years 
before  her  admission,  she  sought  the  advice  of  another  physician, 
equally  skilled,  who  confirmed  the  previous  diagnosis.  Although  her 
general  health  remained  good,  the  irritation  of  the  bladder  gradually 
increased,  until  she  came  under  my  observation. 

I  found  a  cystocele  existing,  which  presented  at  the  labia,  and  was 
due  to  the  crowding  forward  of  an  enlarged  uterus,  wliich  was  partially 
retroverted  from  what  seemed  to  be  a  large  nodulated  fibrous  tumor 
on  its  posterior  wall.  By  placing  the  forefinger  of  one  hand  in  the 
vagina,  and  with  the  aid  of  the  other  over  the  relaxed  walls  of  the 
abdomen,  I  was  able,  without  difficvdty,  and  without  producing  pain, 
to  antevert  the  uterus.  As  I  elevated  the  cervix  on  the  point  of  my 
finger,  while  the  fundus  was  thrown  forward  against  the  pubes,  I 
made  the  tumor  evident  to  several  gentlemen  connected  with  the 
Institution.  By  this  means  I  shoAved  with  what  facility  the  size  and 
relation  of  the  tumor  to  the  uterus  could  be  accurately  mapped  out 
through  the  abdominal  Avail. 

December  1.  I  operated  for  the  relief  of  the  cystocele,  turning  in 
the  excess  of  tissue  by  bringing  together  the  denuded  surfaces  Avith 
interrupted  silver  sutures.  On  remoAdng  the  sutures,  the  line  of  union 
was  found  perfect,  Avith  the  exception  of  half  an  inch  near  the  neck  of 
the  bladder,  Avhere  several  sutures  had  torn  out.  After  a  fcAV  davs, 
she  sat  up,  Avithout  having  had  a  bad  symptom,  but  did  not  regain  her 
strength  rapidly.  She  Avas,  hoAvever, entirely  relieved  of  all  irritation 
of  the  bladder,  and  she  considered  herself  cured. 

On  Friday,  Jan.  22,  I  closed  the  small  opening  in  a  fcAV  moments 
Avith  four  sutures,  and  Avithout  ether.  The  tissues  Avhich  I  had  turned 
in  had  protruded  through  this  opening,  and  I  feared  that  this  might 
cause  the  Avholeline  gradually  to  separate.  Nothing  unusual  occurred 
in  her  condition  until  Sunday  afternoon,  Avhen  she  had  a  slight  move- 
ment from  the  boAvels,  Avhich  was  exceedingly  offensiA^e.  Shortly 
afterAvards,  the  expression  of  the  patient's  face  indicated  that  some 
trouble  Avas  brewing,  but  there  Avere  no  special  symptoms  to  indicate 
Avhat  it  Avas.  The  pulse  Avas  ninety-fiA^e  per  minute,  the  skin  and 
tongue  in  a  normal  condition,  and  the  abdomen  free  from  tenderness 
on  pressure. 

No  change  took  place  until  fiA^e  o'clock,  Monday  afternoon,  when 
suddenly  she  had  two  copious,  fetid  evacuations  per  rectum.  The 
pulse  rose  rapidly  to  170,  the  tongue  became  dry,  the  body  covered 
with  a  clammy  SAveat,  and  she  sank  into  a  profound  collapse.  By 
means  of  stimulants,  heat  to  the  extremities,  and  constant  friction  to 
the  surface  of  the  body  continued  during  the  night,  she  partially 
rallied.  During  Tuesday  her  condition  improved  somcAvhat,  but  she 
then  began  to  shoAV  symptoms  of  blood-poisoning.  About  scA^en  P.  M. 
she  suddenly  had  another  large  offensive  evacuation  from  the  boAvels 
18 


274  DISEASES    OF    THE    PELVIC    CELLULAR    TISSUE. 

■which  was  now  recognized  as  pus.     She  sank  rai^idlj,  and  died  shortly 
afterwards. 

The  follow  in  cr  morning  a  post-mortem  examination  was  made.  On 
opening  the  abdomen,  the  peritoneum  was  found  in  a  healthy  condition. 
The  supposed  fibrous  tumor  proved  to  have  been  a  large  abscess,  with 
several  smaller  ones  in  connection  Avith  it,  between  the  peritoneum  and 
uterus,  and  it  had  ruptured  into  the  rectum.  These  abscesses  were 
encysted  within  a  common  sac,  and  free  from  adhesions  above,  except, 
at  one  point,  to  a  portion  of  the  small  intestines,  in  the  separating  of 
which,  for  removal,  the  large  sac  was  entered.  The  other  adhesions 
extended  along  the  bottom  of  the  cul-de-sac,  from  the  uterus  to  the 
rectum.  Some  thickening  of  the  left  broad  ligament  was  found  which 
had  resulted  from  a  previous  attack,  but  the  surrounding  tissues  were 
entirely  free  from  any  appearance  of  recent  inflammation.  The  other 
organs  were  in  a  healthy  condition  ;  the  brain  was  not  examined. 

In  regard  to  the  diagnosis,  I  fear  that  I  would  be  liable  to  fall  into 
error  in  any  similar  case  not  presenting  a  previous  history  more  to  the 
point,  and  where  the  patient  was  in  good  health,  the  uterus  being 
somewhat  enlarged,  and  menstruation  more  profuse  than  natural.  The 
absence  of  fluctuation  was  due  to  the  density  of  the  outer  cyst,  while 
the  mobility  of  the  uterus,  the  mass  in  connection  with  it,  and  its  nod- 
ulated surface,  added  greatly  to  the  perplexity.  My  diagnosis  was 
made  after  a  careful  examination,  and  without  anj  knowledge  what- 
ever of  the  opinions  which  had  been  previously  given  in  her  case.  In 
fact,  I  did  not  learn  until  after  her  death,  that  she  had  consulted  other 
gentlemen.  The  statement  was  then  made  to  me  bv  her  friends,  as  I 
was  endeavoring  to  trace  her  previous  history  in  regard  to  the  time  of 
formation  of  the  abscess. 

The  point  of  interest  in  her  case  lies  in  the  fact  that  she  had 
been  a  healthy  Avoman,  attending  to  her  daily  duties  for  at  least 
three  years  previous  to  admission.  During  this  time  she  had  suf- 
fered from  no  inconvenience  beyond  that  to  be  attributed  to  the 
existence  of  the  cystocele,  which  was  entirely  relieved  by  the  opera- 
tion. She  dated  the  beginning  of  her  troubles  to  the  birth  of  twins 
five  years  before  admission ;  and  it  Avas  thought  her  tedious  labor  Avas 
due  to  the  fibrous  tumor  detected  shortly  afterwards.  Her  difficult 
labor  two  years  subsequent  to  the  first  Avould  be  naturally  explained 
by  the  presence  of  the  mass  behind  the  uterus,  Avhich  Avas  also  pro- 
nounced at.  this  time  a  fibrous  tumor.  After  this  time,  during  the 
three  years  previous  to  ray  first  examination,  the  irritability  of  the 
bladder  was  constant,  except  Avhile  she  Avas  in  the  recumbent  position. 
Tlie  inference  is,  therefore,  a  natural  one,  that  a  mass  had  existed 
behind  the  uterus  for  at  least  five  years.     The  question  as  to  its 


TREATMENT    OF    CELLULITIS.  275 

character  at  once  presents  itself — either  these  abscesses  formed  after 
labor,  or  they  were  a  result  of  the  breaking  down  of  a  fibrous  tumor, 
producing  no  constitutional  disturbance  or  recognized  local  inflamma- 
tion. From  my  examination  of  the  specimen,  my  impression  is  that 
they  were  primary  abscesses,  for  I  am  not  aware  that  such  a  change 
taking  place  in  a  fibrous  tumor  has  been  observed  or  placed  on  record. 

Examples  are  not  w^anting  in  other  parts  of  the  body.  For  instance, 
within  the  tunica  vaginalis  testis  cheesy  degeneration  may  take  place, 
Avhich  sometimes  breaks  dowai  into  pus  and  remains  for  years  without 
producing  any  disturbance. 

Treatment  of  Pelvic  Cellulitis. — At  the  first  indication  of  a  chill 
the  patient  must  be  put  into  bed,  and  every  effort  made  to  bring  about 
a  reaction.  The  continued  application  of  heat  must  be  made  to  the 
feet,  as  they  will  invariably  be  found  cold.  A  warm  drink  will  be  of 
benefit,  to  which  some  stimulant  may  be  added  if  needed,  and  a  large 
hot  flaxseed  poultice  should  be  placed  over  the  abdomen.  With  reac- 
tion and  pain,  ten  or  fifteen  grains  of  Dover's  powder  may  be  given, 
and,  at  the  same  time,  a  hot-water  vaginal  injection.  When  the 
patient  is  placed  on  a  bed- pan  for  this  purpose,  her  position  must  be 
made  as  comfortable  as  possible  by  the  use  of  an  extra  pillow,  of  a 
proper  size,  under  her  back. 

This  injection  should  be  continued  literally /or  hours,  if  possible, 
and  be  repeated  at  short  intervals.  It  is  the  only  means  Ave  possess 
for  aborting  an  attack  of  cellulitis,  which  it  will  do,  if  thoroughly  em- 
ployed at  the  beginning.  The  patient  will  be  fully  compensated  for 
the  temporary  inconvenience  and  annoyance,  since  this  treatment  may 
prove  the  means  of  saving  her,  in  all  probability,  many  months  of 
sufiering. 

While  receiving  the  injection  it  is,  therefore,  necessary  that  the  posi- 
tion of  the  patient  should  be  a  comfortable  one,  and  the  greatest  care 
must  be  observed  in  protecting  her  from  exposure  to  cold.  Unless 
tbe  nozzle  of  the  injection  pipe  be  made  of  horn,  or  some  other 
non-conductor  of  heat,  it  will  be  necessary  to  cover  it  with  a  piece 
of  India-rubber  tubing.  This  is  essential,  for  the  patient  will  be 
annoyed  exceedingly  by  the  heat  of  a  metallic  nozzle  between  the 
labia,  even  at  a  temperature  for  the  water  far  below  what  could  be 
well  borne  if  introduced  through  a  pipe  of  non-conducting  material. 
A  Davidson's  syringe,  or  some  other  instrument  on  the  same  principle, 
must  be  employed  in  preference  to  a  fountain  syringe.  This  is  not 
an  unimportant  detail,  for,  if  the  experiment  be  made  by  any  one  of 
ordinary  powers  of  observation  he  will  be  convinced  that  the  impulse 


276  DISEASES    OF    THE    PELVIC    CELLULAR    TISSUE. 

of  the  jet  of  water  is  needed  to  excite  the  proper  contraction  of  the 
vessels.  A  piece  of  rubber  tubing  can  be  attached  to  the  bed-pan,  so 
as  to  carry  off  the  overflow  of  water  to  some  receptacle  under  the  bed. 
This  can  be  emptied  from  time  to  time  without  disturbing  the  patient. 
The  water  must  be  injected  slowly,  but  in  a  steady  stream,  and  at  as 
elevated  a  temperature  as  can  be  borne  with  comfort.  The  hands  of 
any  one  person  will  soon  become  cramped,  in  continuously  squeezing 
the  ball  of  the  syringe,  so  that  it  will  be  necessary  to  have  the  assist- 
ance of  another. 

The  best  rule  is  to  continue  the  injection  until  reaction  has  fully 
taken  place,  by  which  time  the  fever  will  have  subsided,  and  a  free 
action  of  the  skin  Avill  have  been  established.  Whenever  it  is  possible 
to  prolong  this  action  of  the  skin  by  the  use  of  the  liquor  ammonias 
acetatis,  or  by  any  other  remedy,  it  should  be  done.  Nothing  would 
b3  better  than  a  Russian  bath,  if  it  were  available  without  involving 
the  risks  of  exposure,  and  without  entailing  additional  pain  from  the 
movements  which  would  be  necessary.  The  use  of  the  hot  water  is 
usually  very  grateful,  and,  as  it  evaporates  under  the  bedclothing, 
the  action  of  the  skin  is  thereby  inuch  increased. 

The  continued  action  of  the  hot  water  is  to  stimulate  the  circulation 
in  the  pelvis,  so  that  the  local  congestion  may  be  relieved,  before 
nature  attempts  to  do  so  by  the  exudation  of  serum  into  the  surround- 
ins:  tissues.  With  this  view,  it  will  be  seen  that  an  increased  action 
of  the  skin  must  be  most  beneficial,  and  should  be  kept  up  as  long 
as  possible. 

Another  remedy  to  be  employed  for  relieving  the  congestion  is 
opium,  which,  for  its  local  effect,  is  best  given  in  the  form  of  an  in- 
jection into  the  rectum.  At  all  hazards,  the  local  irritation,  as  ex- 
pressed by  pain,  must  be  quieted,  or  the  current  of  blood  will  con- 
tinue to  flow  towards  the  congested  part.  Unfortunately,  there  is  but 
a  very  short  time  at  the  beginning,  when  it  will  be  possible  to  abort  the 
attack,  and  in  a  few  hours  the  storm  will  have  inflicted  much  damage. 

The  next  stage  will  be  a  critical  one,  and  will  test  to  the  utmost 
the  recuperative  powers  possessed  by  the  individual.  Nature  will 
now  make  the  effort  to  repair,  by  aid  of  the  absorbents,  the  damage 
done,  and  will  rapidly  accomplish  the  task  if  the  progress  of  the 
inflammation  c£tn  be  arrested. 

This  stage  is  one  of  uncertain  duration,  lasting  from  a  few  hours  to 
days,  and  is,  as  a  rule,  the  one  first  seen  by  the  physician,  although 
not  always  recognized.  The  tissues  have  become  infiltrated  with 
serum,  a  local  elevation  of  temperature  exists  in  the  vagina,  the  uterus 


TREATMENT    OF    CELLULITIS.  277 

may  be  movable,  and,  if  the  peritoneum  has  become  involved,  the  in- 
flammation is  yet  circumscribed,  and  no  lymph  has  been  thrown  out. 
There  will  have  been  already  a  great  mitigation  in  the  degree  of  pain, 
and  there  may  be  even  an  absence  of  fever. 

Rest  in  the  recumbent  posture  is  absolutely  called  for,  the  body 
must  be  protected  from  cold  by  an  extra  amount  of  flannel,  and  the 
extremities  kept  at  a  comfortable  temperature  by  artificial  means.  If 
there  is  pain  on  pressure,  it  is  the  usual  recommendation  to  apply  a 
number  of  leeches  to  the  abdominal  wall  over  the  seat  of  pain.  Some 
temporary  relief  at  least  is  frequently  gained  by  this  practice,  but  it 
is  not  to  be  followed,  unless  under  some  special  circumstance.  As  the 
restoration  to  health  depends  on  the  patient's  strength,  this  must  not  be 
impaired  by  the  abstraction  of  blood,  of  which  the  benefit  may  be  only 
temporary.  Counter-irritation  is  of  great  service,  and  a  marked  im- 
provement will  be  frequently  noticed  after  the  application  of  a  blister. 
It  is  to  be  applied  over  the  seat  of  pain,  but  with  the  precaution  to 
avoid  the  groin,  or  the  patient  will  be  subjected  to  much  unnecessary 
sufiiering.  By  using  a  mustard  plaster  at  first  to  redden  the  skin,  a 
more  certain  result  will  be  obtained  from  the  blister.  When  the 
material  is  good,  six  to  eight  hours  should  be  sufficient  for  the  blister 
to  remain.  It  may  then  be  removed,  and  the  surface  covered  by  a 
soft  poultice  protected  on  the  outside  by  a  piece  of  oil-silk.  Then  the 
whole  may  be  secured  by  a  light  flannel  binder,  which  should  be  worn 
as  a  protector  whenever  the  abdomen  is  not  covered  by  a  large 
poultice.  The  poultice  may  be  removed  after  a  few  hours  as  it  be- 
comes cool,  and  the  several  blebs  formed  by  the  blister  are  to  be 
cut  to  allow  the  fluid  to  escape.  After  they  have  been  emptied,  the 
whole  surface,  which  had  been  covered  by  the  poultice,  must  be 
quickly  wiped  off"  with  a  soft  sponge  dipped  into  warm  water,  and  with 
a  little  soap.  Over  this  surface,  when  dried,  is  to  be  placed  some 
loose  cotton  of  the  best  quality.  As  it  is  a  great  object  to  husband 
the  strength  of  the  patient,  it  is  necessary  to  heal  the  blister,  and  with 
as  little  discharge  as  possible.  Nothing  will  do  this  sooner  than 
cotton,  which  should  be  allowed  to  stick  to  the  raw  surface,  and  re- 
main undisturbed  until  it  falls  off"  after  the  surface  beneath  has  become 
healed.  After  a  day  or  two  all  the  cotton  which  can  be  removed 
Avithout  force  can  be  taken  away,  and  the  rest  must  be  softened  some- 
what by  the  application  of  a  sponge  moistened  with  warm  water  and  a 
little  carbolic  acid.  Then  the  surface  must  be  dried  with  a  soft  towel, 
and  again  covered  loosely  with  fresh  cotton.  This  must  be  repeated 
daily,  if  any  odor  can  be  detected,  or  if  the  patient  should  complain 


278  DISEASES    OF    THE    PELVIC    CELLULAR    TISSUE. 

of  its  being  uncomfortable.     A  blister  can  thus  be   applied   every 
twelve  or  fourteen  days  until  the  necessity  no  longer  exists  for  its  use. 

The  iodide  of  potassium  is  frequently  used  as  an  alterative  in  this 
condition,  but  it  is  not  always  reliable.  I  have  seen  the  condition  of 
a  patient  improve  rapidly  while  taking  it,  and  again  I  have  seen  not 
the  slightest  good  result  from  its  use.  The  same  observation  may  be 
applied  with  equal  force  to  the  use  of  small  and  frequent  doses  of 
calomel.  There  are  certain  conditions  where  each  of  these  agents 
S3ems  to  be  efficacious,  but  with  our  present  knowledge  their  use  is 
somewhat  empirical. 

We  must  employ  every  means  calculated  to  improve  the  general 
health.  Tonics  may  be  needed,  but  the  use  of  iron  in  any  form  should 
be  avoided  if  possible,  on  account  of  its  constipating  eifect.  To  regu- 
late the  bowels  during  the  later  stages  of  cellulitis  will  prove  a  problem 
very  difficult  of  solution.  The  food  should  be  given  in  the  most  con- 
centrated form,  and  the  selection  made  so  that  the  greater  part  will 
be  assimilated,  leaving  but  little  residue  to  accumulate.  It  is  all- 
essential- to  prevent  an  accumulation  in  the  boAvels,  since  this  con- 
dition, by  acting  mechanically,  must  obstinict  the  return  circulation 
from  the  pelvis.  On  the  other  hand,  much  distress  and  increase  of 
pain  are  caused  by  any  distension  of  that  portion  of  the  rectum  pai'tially 
constricted  by  the  cellulitis.  It  is  necessary  to  have  the  contents  of 
the  bowels  in  a  semi-fluid  condition,  since  the  patient  is  either  unable 
to  strain,  or  instinctively  avoids  doing  so,  through  fear  of  causing 
pain.  It  is  essential  to  keep  the  rectum  empty,  for  the  pressure 
of  any  fecal  mass  will  add  greatly  to  her  discomfort.  The  diffi- 
culty of  managing  these  cases  is  greatly  increased  by  the  fact  that 
few  are  able  to  tolerate  a  rectal  enema,  except  in  so  small  a  bulk  as  to 
be  of  but  little  service.  Any  distension  of  the  rectum,  even  in  this 
way  by  fluid,  must  necessarily  make  pressure  on  the  inflamed  tissues. 
Scybalse  will  frequently  form  notwithstanding  all  care,  and,  when  in 
the  rectum,  the  patient  is  generally  unable  to  effect  their  expul- 
sion. I  instruct  my  nurses  to  introduce  a  finger,  well  oiled,  into 
the  rectum  to  remove  any  accumulation  there  may  be,  as  soon  as  the 
patient  begins  to  realize  any  discomfort.  This  requires  some  little 
expertness,  for  any  approach  to  violence  will  produce  much  unneces- 
sary suffering.  '  The  operation,  therefore,  is  well  Avorthy  of  the 
physician's  personal  attention,  even  if  he  has  to  administer  the  relief 
himself.  A  few  ounces  of  warm  flaxseed  tea,  or  oil,  may  be  thrown 
into  the  rectum,  and  then  any  hardened  mass  can  be  the  more  readily 
removed.     The  index  finger  is  to  be  gently  passed  in  front  and  beyond 


TREATMENT    OF    CELLULITIS.  279 

the  mass,  so  that  the  necessary  force  for  the  removal  can  be  exerted 
downwards  and  backwards  towards  the  sacrum,  and  thus  avoid  pres- 
sure against  the  seat  of  inflaunnation.  Sulphur  in  combination  with 
the  bitartrate  of  potassa  ansAvers  well,  as  does  an  occasional  dose  of 
castor  oil.  I  have  had  women  under  my  care  who  were  fortunately 
able  to  take  every  night  a  spoonful  of  castor  oil  Avhich  regulated  the 
bowels  perfectly  without  causing  any  disturbance  of  the  digestion. 
Occasionally,  it  is  good  practice  to  give  a  pill  containing  five  grains 
of  inspissated  ox-gall  three  times  a  day,  and  if  there  be  any  flatulence, 
four  grains  of  assafoetida  in  a  sugar-coated  pill,  may  be  added,  pro- 
vided it  can  be  taken  without  disturbance  to  the  stomach.  Our  first 
care  must  be  to  spare  this  organ,  and  we  must  never  lose  sight  of  this 
necessity.  From  reflex  action,  the  stomach  would  naturally  be  liable 
to  derangement  through  sympathy  with  the  pelvic  condition.  The 
necessity  is,  therefore,  the  greater  to  aid  digestion  by  judicious  means, 
and  to  avoid  over- taxing  the  stomach.  In  other  words,  we  must  have 
it  at  rest,  as  far  as  posssible,  when  not  necessarily  engaged  in  diges- 
tion, for,  as  soon  as  nutrition  becomes  impaired  through  failure  of  the 
digestive  powers,  recuperation  ceases. 

Whenever  a  patient  is  able  to  take  cod-liver  oil  without  deranging 
the  digestion,  it  will  prove  a  most  fortunate  circumstance,  as  this 
remedy  is  very  eifective  in  repairing  the  Avaste. 

Of  all  the  diseases  and  complications  we  may  be  called  on  to  treat 
in  this  branch  of  surgery,  we  will  find  none  in  which  sunlight  and 
fresh  air  prove  so  beneficial  and  essential  as  in  pelvic  abscess.  Unless 
it  be  during  the  mildest  season  of  the  year,  a  patient  suffering  from 
this  disease  will  tolerate  but  little  exposure,  from  being  so  sensitive  to 
the  effects  of  cold.  She  should  occupy  a  bright,  sunny  room,  and,  as 
far  as  possible,  she  should  carry  out  the  suggestions  I  have  already 
given  on  this  subject. 

The  vaginal  injections  of  hot  water  are  to  be  continued  throughout 
the  progress  of  the  case,  and  are  best  administered  early  in  the 
morning  and  at  night.  A  large  basinful  will  answer  every  purpose, 
for  the  time  has  now  passed  when  the  continued  use  of  this  agent  can 
be  beneficial  as  a  prophylactic.  But  it  may  indirectly  stimulate  the 
absorbents  and  diminish  somewhat  the  pelvic  circulation,  and  soothe 
the  general  system  by  temporarily  relieving  the  local  irritation.  It 
thus  gives  great  comfort,  and  is  most  useful  in  inducing  sleep,  when 
employed  as  the  last  thing  after  the  patient  has  been  prepared  for  the 
night. 

A  judicious  use  of  opium  and  anodynes  generally  will  require  a 


280  DISEASES    OF    THE    PELVIC    CELLULAR    TISSUE. 

discriminating  exercise  of  judgment  on  the  part  of  the  physician. 
These  remedies  are  to  be  held  in  reserve  for  a  last  resort,  as  the 
sheet  anchor  to  the  threatened  wreck.  There  is  a  period  always  to 
this  disease,  if  it  becomes  general,  when  an  opiate  furnishes  almost 
the  only  hold  on  life.  It  is  then  the  only  effective  agent  left,  and 
acts  as  a  tonic,  by  allaying  pain,  affording  rest,  and  checking  the 
waste  to  the  nervous  system.  I  am  certain  that  I  have  seen  cases 
where  recovery  Avas  due  alone  to  the  anodynes  having  been  held  in 
reserve.  The  common  practice  is  to  get  the  patient  so  dependent  on 
their  use  in  the  early  stages  of  the  disease,  that  when  most  needed, 
their  good  effects  are  not  obtained,  such  large  doses  becoming  neces- 
sary, that  the  appetite  and  the  digestion  are  impaired  by  their  use. 
It  would  be  a  bad  plan  ever  to  allow  the  patient  to  actually  suffer 
from  pain,  but  there  are  times  when  the  hot-water  injections  or  some 
other  mild  means  would  answer.  But  when  an  opiate  is  necessary, 
as  I  have  already  recommended,  let  it  be  always  administered  either 
by  injection  or  by  a  suppository  in  the  rectum,  and  let  its  use  thus 
be  made  as  little  a  matter  of  routine  as  possible.  Of  all  modes, 
that  by  the  hypodermic  syringe  is  the  most  dangerous,  since  it  can 
be  so  readily  employed.  The  inventor  of  this  method  has  given,  I 
fear,  a  curse  to  the  human  race  instead  of  a  blessing.  I  may  be 
deemed  prejudiced,  but  I  have  long  felt  that  the  medical  profession 
is  largely  responsible  in  the  abuse  of  this  instrument,  for  the  wide- 
spread existence  of  the  opium  habit.  This  vice  is  increasing  so 
rapidly  all  over  the  country,  that  we  shall,  to  our  sorrow,  at  no  dis- 
tant day,  rival  the  Chinese  in  the  consumption  of  this  drug. 

For  convenience  of  description,  we  may  make  a  third  stage  in  this 
disease,  that  of  exudation.  But,  in  practice,  the  stage  of  infiltration, 
if  not  arrested  by  convalescence,  passes  so  rapidly  into  that  of  exuda- 
tion that  the  two  stages  may  be  regarded  as  one,  the  same  course  of 
treatment  being  applicable. 

Then,  in  turn,  if  the  stage  of  exudation  and  its  progress  be  not 
arrested  and  followed  by  recovery,  we  must  expect  the  most  serious 
condition,  that  of  the  formation  of  pus.  This  is  ushered  in  by  the 
occurrence  of  rigors  from  time  to  time,  followed  by  fever  and  with 
increase  of  pain.  The  pus  formed  by  the  disintegration  of  tissue  is  at 
first  scattered  about  in  small  masses  which  in  time  break  down  the 
intervening  tissues  and  form  one  or  more  abscesses.  These  abscesses 
sometimes  promptly  find  an  outlet,  convalescence  begins  at  once,  and 
the  sac  rapidly  disappears.  But,  with  many,  the  cavity  remains  open 
for  an  indefinite  period,  its  lining  membrane  forming  a  pus-secreting 


TREATMENT    OF    CELLULITIS.  281 

surface.  The  danger  to  the  patient  is  now  greater  than  at  any  other 
stage  of  this  disease.  In  addition  to  the  great  draft  made  on  the 
system  by  the  profuse  discliarge  of  pus,  the  patient,  in  all  likelihood, 
begins  to  suffer  hectic  or  irritative  fever  and  blood  poisoning.  So 
long  as  the  pus  remains  sacculated,  the  latter  danger  is  slight,  but, 
after  the  abscess  has  been  emptied  of  its  contents,  nature  makes  an 
effort  to  remove  the  difficulty  by  absorption.  So  in  the  progress  of 
the  last  stage  of  this  disease  the  system  is  being  constantly  poisoned, 
and  as  long  as  sufficient  strength  remains,  the  poison  will  be  elimi- 
nated. 

Quinia,  opium,  and  the  most  nutritious  diet  will  be  now  the  chief 
means  for  sustaining  the  patient.  There  will  scarcely  ever  be  more 
than  a  remission  of  fever  in  this  stage,  but  by  watching  the  temperature 
as  it  varies  in  the  vagina  it  will  be  seen  that  there  is  almost  always 
an  increase  of  fever  between  noon  and  midnight.  This  condition  and 
the  tendency  to  blood  poisoning  must  be  kept  in  check  by  the  use  of 
quinia  in  large  doses,  which,  it  is  well  known,  possesses  the  property 
of  lessening  the  frequency  of  the  pulse  and  lowering  the  temperature. 
Quinia  is  said  to  possess  the  further  property  of  limiting  the  migra- 
tion of  white  corpuscles  and  the  formation  of  pus,  which,  if  it  is  true, 
gives  it  additional  value  in  this  disease.  From  recent  observations, 
it  is  claimed  that  with  double  the  quantity  of  the  bromide  of  potas- 
sium, or  with  hydrobromic  acid,  quinine  may  be  given  in  large  doses 
without  the  occurrence  of  quinism,  and  without  impairing  its  own 
properties.  My  experience  has  yet  been  limited,  but  so  far  as  it 
goes  it  is  favorable  to  the  combination.  We  have  another  resource 
of  value  in  the  careful  use  of  aconite,  as  the  vital  powers  become  im- 
paired, and  the  action  of  the  heart  is  necessarily  rendered  more  fre- 
quent from  a  diminution  of  its  force.  It  is  to  be  employed  for  its 
tonic  effect  on  the  heart  itself,  by  which  the  organ  will  be  better  able 
to  do  its  work.  Under  the  influence  of  this  remedy  the  heart  will  be 
able  to  expel  the  same  quantity  of  blood  by  a  fewer  number  of  con- 
tractions than  before,  when  the  increase  of  frequency  was  due  to  an 
enfeebled  condition,  and  not  to  increased  force.  As  soon  as  the 
number  of  contractions  of  the  heart  has  been  reduced  twenty  beats  in 
the  minute,  it  is  safer  to  lessen  somewhat  the  dose  and  watch  its  effects. 
While  under  the  effects  of  aconite,  it  is  even  the  more  important  that 
the  patient  should  be  nourished  with  regularity  and  care.  Moderate 
doses  of  stimulants,  if  needed,  may  be  used,  since  they  will  also  lessen 
the  frequency  of  the  pulse,  and  materially  aid  the  action  of  the 
aconite. 


282  DISEASES    OF    THE    PELVIC    CELLULAR    TISSUE. 

Yery  few  of  the  thermometers  sold  by  the  instrument-makers  are 
reliable.  They  are  not  fit  for  use  until  at  least  a  year  after  they  have 
been  made,  since  the  tubes  contract,  and  the  scales,  if  adjusted  too  soon, 
give  erroneous  indications.  They  should  never  be  graduated  until  all 
shrinkage  in  the  glass  has  ceased.  I  have  noted  a  difference  of  as 
much  as  three  degrees  between  two  instruments  from  the  same  maker. 

An  elevation  of  two  or  three  degrees  above  the  natural  temperature 
of  the  body  is  of  but  little  moment  in  an  attack  of  cellulitis.  But  if  a 
reliable  instrument  registers  the  temperature  at  105°,  the  condition  is 
a  very  serious  one,  and  but  few  recover  if  the  temperature  remains 
above  this  point  for  any  length  of  time.  The  higher  the  range  of 
temperature  the  more  certain  will  it  be  an  indication  of  the  peritoneum 
being  involved  and  of  the  extension  of  the  inflammation. 

The  rule  is  as  applicable  here  as  in  general  surgery,  to  open  freely 
a  collection  of  pus  as  soon  as  it  can  be  detected,  I  do  not  regard  it 
as  sound  practice  to  wait  until  the  pus  finds  an  outlet  for  itself .  There 
is  no  possible  way  by  which  the  contents  of  an  abscess  could  be  dis- 
posed of  except  by  rupture.  It  is,  therefore,  the  safest  procedure  to 
open  the  abscess  through  the  vagina  as  soon  as  the  presence  of  the  pus 
can  be  detected.  This,  however,  is  sometimes  very  uncertain  unless 
the  walls  are  thin,  for  the  sensation  of  fluctuation  may  be  well  marked 
and  yet  no  collection  of  fluid  be  found.  But,  Avhen  we  are  sure  of 
the  existence  of  the  abscess,  there  can  be  nothing  gained  by  allowing 
its  contents  to  burrow  to  a  greater  extent  through  the  tissues,  with  the 
possibility  of  escape  into  the  peritoneal  cavity.  Whether  the  abscess 
has  ruptured  into  the  vagina,  or  been  evacuated  artificially,  the  open- 
ing must  be  sufficient  to  admit  of  the  cavity  being  thoroughly  washed 
out.  I  employ  warm  water  with  a  little  impure  carbolic  acid  or  an 
injection  of  warm  water  through  which  a  few  spoonfuls  of  brewer's 
yeast  have  been  diffused.  The  irritative  fever  will  lessen  as  the  cavity 
contracts,  and  its  lining  membrane  brought  into  a  more  healthy  con- 
dition so  that  the  discharge  from  it  becomes  greatly  diminished. 
The  opening  should  be  at  the  most  dependent  portion,  if  possible, 
although  this  cannot  always  be  a  matter  of  selection,  but  is  a  fortu- 
nate circumstance  when  it  happens,  because  thereby  the  cavity  more 
easily  contracts  from  being  properly  drained.  With  a  free  opening, 
admitting  the  ready  access  of  air,  the  discharge  will  increase  for  a  time 
and  become  more  offensive,  but  this  can  be  greatly  lessened  by  washing 
out  the  cavity.  The  vaginal  injections  are  to  be  continued,  and  may 
be  given  by  the  nurse  as  a  means  of  keeping  the  canal  free  from  de- 
composing pus.     But  the  washing  out  of  the  tract  of  the  abscess  should 


PELVIC    ABSCESS.  .    283 

never  be  devolved  by  the  surgeon  upon  an  assistant.  The  operation 
requires  judgment,  and  the  water  should  be  thrown  from  a  long  nozzle 
glass  syringe,  Avithout  force,  and  with  care.  This  is  a  necessary  pre- 
caution, since  I  have  known  of  two  instances  where  the  sac  was  rup- 
tured and  death  ensued  from  the  contents  passing  into  the  abdominal 
cavity.  This  danger  is  a  temporary  one  at  the  beginning,  for  nature 
will  soon  form  some  adhesion  or  thickening  at  any  weak  point  after  which 
this  accident  cannot  occur.  The  nozzle  of  the  syringe  must  be  turned 
in  different  directions  so  as  to  wash  off  the  sides  of  the  cavity,  and  the 
injection  is  to  be  continued  until  the  water  comes  away  clear.  After 
I  have  continued  to  wash  out  a  cavity  for  some  time,  and  the  condi- 
tion of  the  patient  may  have  ceased  to  improve,  I  inject  a  weak  solu- 
tion of  iodine  and  water.  If  no  particular  disturbance  be  caused,  I 
increase  its  strength  in  a  few  days,  and  watch  the  effect.  The  object 
is  to  destroy  the  pyogenic  surface  by  a  solution  strong  enough  to 
effect  the  purpose,  without  lighting  up  a  fresh  attack  of  cellulitis. 

A  pelvic  abscess  does  not  often  empty  into  the  rectum  alone,  but 
frequently  it  does  into  both  the  rectum  and  vagina  in  the  same  case. 
An  additional  opening  into  the  rectum  complicates  the  case  very  much, 
and  the  result  is  never  so  favorable  as  when  the  opening  is  only  into 
the  vagina.  With  an  opening  into  the  rectum  the  discharge  is  always 
more  profuse  from  the  presence  of  fecal  matter,  or,  if  the  opening  is  so 
situated  that  the  passage  of  feces  does  not  take  place  through  it,  the 
escape  of  flatus  will  prove  almost  as  irritating.  Unless  the  tract  of 
the  abscess  can  be  washed  out  from  the  vagina,  we  will  be  obliged  to 
rely  chiefly  on  the  endurance  of  the  patient  for  recovery. 

I  have  met  with  but  a  single  instance  of  an  abscess  forming  in  the 
cellular  tissue  between  the  uterus,  bladder,  and  vagina.  The  case 
came  under  my  care  a  year  or  more  after  the  abscess  had  ruptured 
into  the  bladder,  and  in  consequence  of  the  escape  of  urine  through 
the  vaginal  canal.  Through  an  opening  located  in  the  median  line, 
and  iu  the  centre  of  the  vesico-vaginal  septum,  a  probe  passed  back 
alono-  a  sinus  to  the  uterus,  but  did  not  enter  the  bladder.  With  a 
pair  of  blunt-pointed  scissors,  I  laid  open  the  tract  until  I  reached  the 
small  cavity  which  had  been  the  seat  of  the  abscess,  and  through. a 
thin  anterior  wall  a  small  opening  was  found  passing  directly  into  the 
bladder.  The  sides  of  this  cavity  were  carefully  freshened  by  means 
of  a  pair  of  scissors,  and  Avhen  too  thin  were  scraped,  so  as  to  obtain 
a  denuded  surface.  Interrupted  sutures  were  then  introduced  and  the 
sides  of  the  cavity  brought  together  in  the  median  line. 

Two  instances  of  cellulitis  have  passed  under  my  observation,  in 


284  DISEASES    OF    THE    PELVIC    CELLULAR    TISSUE. 

■which  the  urine  escaped  directly  into  the  vagina  from  the  left  ureter. 
In  one  case  the  ureter  seemed  to  have  formed  an  adhesion  to  the 
vaginal  wall  just  behind  the  junction  of  the  posterior  cul-de-sac  with 
the  cervix.  The  contents  of  the  abscess  emptied  into  the  bladder, 
vrhile  the  pressure  of  the  accumulation  and  the  pus  produced  so  much 
irritation  that  the  passage  of  urine  from  this  ureter  into  the  bladder 
became  obstructed,  and  forced  its  way  into  the  vagina. 

In  another  case  the  left  ureter  was  cut  across  by  the  surgeon,  at 
precisely  the  same  point,  in  opening  the  abscess,  so  that  both  pus  and 
urine  passed  into  the  vagina.  These  two  cases  will  be  again  referred 
to,  more  in  detail,  under  the  head  of  vesico-vaginal  fistula. 

The  natural  position  of  this  portion  of  the  ureter  is  outside  of  the 
bladder,  and  in  these  two  cases  was  fully  an  inch  above  its  vesical 
orifice.  The  displacement  must  have  been  brought  about  by  the 
weight  and  downward  pressure  of  the  abscess,  and  it  would,  therefore, 
be  well  in  opening  an  abscess  from  the  vagina  to  avoid,  if  possible, 
this  locality. 

Dr.  Erickell,  of  Xew  Orleans,  has  recently  made  an  important 
contribution^  to  this  subject,  and  his  views  are  summed  up  by  himself 
as  follows: — 

"Conclusions  :  1.  I  have  no  doubt  at  all  that  there  are  two  distinct 
forms  of  pelvic  inflammation — serous  and  phlegmonous,  or  suppurative. 
An  attack  of  either  may  be  abortive — that  is,  may  fail  to  result  in 
formation  of  pus  or  effusion  of  serum.  But,  should  either  pus  or 
serum  be  formed,  then 

2.  I  am  sure  that  evacuation  is  the  joroper  practice ;  and 

3.  Either  should  be  evacuated  per  vaginam. 

4.  The  presence  of  pus  in  any  portion  of  the  body  is  not  to  be 
tolerated  by  the  surgeon.  I  contend  that  the  presence  of  effused 
serum  in  the  pelvis  is  not  to  be  tolerated  either.  As  long  as  it  is 
present,  in  addition  to  the  pain  and  prostration,  there  is  the  abiding 
stimulus  to  repeated  inflammation,  and  the  pelvis  can  and  will  be 
ravaged. 

5.  Topical  applications  and  internal  remedies  have  no  influence  on 
pelvic  serous  effiision,  accoixling  to  my  observation." 

Xot  being  in  genei'al  practice,  I  have  seen  but  few  cases  before  the 
abscess  had  already  ruptured.    In  my  own  practice  I  have  also  been  so 

1  The  Proper  Treatment  of  Pelvic  Effusions.  By  D.  Warren  Brickt-ll,  M.D., 
Professor  of  Obstetrics,  etc.,  Charity  Hospital  Medical  College,  New  Orleans. 
American  Journal  of  the  Medical  Sciences,  Philadelphia,  April,  1877. 


TREATMENT    OF    ABSCESS.  285 

fortunate  as  to  have  had  a  very  limited  experience.  Necessarily,  many 
cases  of  cellulitis  have  occurred  in  mv  hands  durins;  the  course  of  treat- 
ment  or  after  operations.  But  durin<2;  sixteen  years'  service  in  the 
Woman's  Hospital  I  cannot  recall  a  single  instance  where  the  inflam- 
mation terminated  in  an  abscess.  During  the  same  time,  in  my  private 
practice,  I  have  had  two  cases  occurring  after  division  of  the  cervix, 
which  I  have  referred  to  when  treating  of  this  operation.  In  fact  I 
have  never  had  the  opportunity  of  opening  more  than  five  or  six  pelvic 
abscesses  in  my  life,  and  I  have  never  met  with  a  collection  of  serum, 
as  described  by  Dr.  Brickell.  In  post-mortem  examinations  of  in- 
flammatory conditions  resulting  from  childbirth,  I  have  so  frequently 
found  the  connective  tissue  infiltrated  with  serum,  that  I  have  always 
regarded  its  presence  as  indicative  of  a  stage  of  the  cellulitis,  which 
would  naturally  terminate  in  a  pelvic  abscess  if  not  arrested.  Dr. 
Brickell  reports  a  number  of  cases  relieved  by  evacuating  accumula- 
tions of  serum  equal  in  quantity  to  the  contents  of  an  abscess.  I  can 
recall  a  number  of  cases  Avhich  have  been  under  my  observation  with 
thickened  tissues,  where  no  treatment  seemed  to  have  had  the  slightest 
effect,  and  finally  they  have  passed  into  other  hands.  It  is  quite 
probable  that  among  this  class  of  cases  will  be  found  these  collections 
of  serum,  since  Dr.  Brickell  does  not  seem  to  have  met  with  an 
instance  whei'e  such  an  accumulation  has  found  an  outlet  without  the 
aid  of  the  knife.  He  cites  a  case  of  a  collection  of  pus  producing  no 
irritation  for  a  length  of  time  after  the  acute  symptoms  had  vanished, 
and  it  is  of  particular  interest  in  connection  with  the  history  of  the 
case  of  supposed  fibroid  recently  given.  Dr.  Brickell  writes:  "  Sup- 
puration, Case  IV.,  cited  by  me,  shows  clearly  how  free  deposits  of 
pus  can  take  place  in  the  pelvis  as  results  of  acute  attacks  of  inflam- 
mation, and  yet,  when  the  acute  symptoms  subside,  the  patient  may 
get  up,  improve  in  appearance,  and  even  work  for  a  living  for  several 
years  in  comparative  comfort.  After  a  while,  however,  active  inflam- 
mation is  relighted,  and  the  result  will  be  destruction."  This  is  not 
the  rule,  however,  with  collections  of  pus,  while  there  are  other  cases, 
as  I  have  stated,  which  are  at  a  standstill  for  years.  In  these  cases 
I  hope  we  may  find  this  accumulation  of  serum,  and  if  they  can  be 
relieved  by  means  of  the  aspirator.  Dr.  Brickell  will  have  indeed  done 
good  service.  But  experience  alone  can  determine  the  proper  time 
for  making  this  exploration,  for  I  cannot  regard  the  introduction  of 
the  trocar  into  the  inflamed  tissues  of  the  pelvis  as  a  procedure  free 
from  danger  under  all  circumstances.  These  remarks  are  prompted 
by  the  recollection  of  two  cases  where,  having  erred  in  my  diagnosis, 


286 


DISEASES    OF    THE    PELVIC    CELLULAR    TISSUE, 


and  getting  no  fluid  on  the  introduction  of  the  trocar,  the  patients' 
lives  were  seriously  jeopardized  by  the  fresh  attack  of  cellulitis  which 
resulted. 

Before  closing  this  subject,  I  will  direct  the  attention  of  the  reader 
to  a  condition  which  does  not  seem  to  have  been  described  by  any 
other  observer.  After  an  attack  of  cellulitis  has  subsided  the  tissues 
which  had  been  inflamed  contract.  When  the  inflammation  has  oc- 
curred in  one  of  the  broad  ligaments,  the  neck  of  the  uterus  will  be 
drawn  towards  the  injured  side  in  consequence  of  this  ligament  be- 
coming shortened.  The  uterus  under  these  circumstances  will  fre- 
quently became  enlarged,  and  it  will  often  be  a  matter  of  surprise  to 
find,  after  a  reasonable  time,  that  there  has  been  no  improvement  in 
the  condition  of  the  uterus,  even  under  the  most  approved  course  of 
treatment.  The  woman  will  become  an  invalid  from  her  inability  to 
exercise,  and  after  awhile  another  attack  of  cellulitis  may  come  on 
without  any  apparent  cause.  If  a  weight  were  hung  by  two  or  more 
cords  of  equal  length,  and  one  of  them  be  wetted,  that  one  to  which 
the  moisture  was  applied  Avould  shorten  so  much  that  the  whole 
weight  would  become  suspended  from  it.     And  so  the  weight  of  the 

uterus  and  its  appendages  will  have  to 
be  sustained  by  the  ligament  or  part 
which  has  been  inflamed  and  shortened. 
The  consequence  will  be  a  state  of 
congestive  irritability,  which  will  not 
only  neutralize  all  remedial  eiforts, 
but  sooner  or  later  will  induce  an 
attack  of  cellulitis  in  the  opposite 
healthy  ligament,  as  a  result  of  the 
constant  one-sided  traction.  If  we 
gently  lift  the  uterus  to  a  given  point, 
on  the  extremity  of  the  finger,  we  will 
generally  find,  as  I  have  already  said 
in  the  early  part  of  this  work,  that  the 
patient  will  experience  the  greatest 
relief  and  the  pulsation  of  the  vessels 
will  gradually  cease. 

The  first  step  to  be  made  towards 
a  restoration  to  health  is  to  lift  and 
maintain  the  uterus  at  a  plane  in  the 
pelvis  at  which  this  traction  will  be  entirely  removed.  Tliis  is  to  be 
accomplished  by  a  pessary  curved  enough  to  lift  the  organ  and  at  the 


Pessary  for  ceUulitis. 


SUPPORT  FOR  THE  UTERUS  IN  CELLULITIS.       287 

same  time  moulded  in  such  a  manner  as  not  to  press  laterally  upon  the 
seat  of  inflammation  or  the  thickened  ligament.  I  have  freciuently 
employed,  for  this  purpose,  an  instrument  formed  from  an  ordinary 
lever  pessary  by  twisting  it  on  itself,  so  that  one  end  may  stand  at  a 
right  angle  to  the  other.  The  front  half  of  the  pessary  remains 
unchanged,  but  the  part  which  would  rest  under  the  inflamed  broad 
ligament  is  bent  over  to  the  opposite  side,  so  as  to  support  the  uterus 
under  the  healthy  broad  ligament,  and  along  half  of  the  posterior 
cul-de-sac,  the  seat  of  the  old  inflammation  not  being  touched  by  the 
instrument.  (See  Fig.  48.) 


DISPLACEMENTS    OF    THE    UTERUS. 


CHAPTER    XIV. 

DISPLACEMENTS  OF  THE  UTERUS. 

Anatomical  supports  of  the  uterus — Normal  position  of  the  uterus — Pelvic  roof — 
Downward  displacements,  or  prolapse — Causes — Versions  ;  forward,  backward, 
lateral — Causes  of  versions — Flexures. 

The  uterus  receives  its  support  from  the  utero-sacral  ligaments 
behind,  the  broad  ligaments  on  either  side,  the  round  ligaments  in 
front,  and  from  the  connective  tissue  of  the  pelvis. 

As  the  peritoneum  dips  down  between  the  organs  and  over  the 
Fallopian  tubes,  it  includes  a  certain  amount  of  the  cellular,  or  con- 
nective, tissue  between  its  folds,  which,  with  a  few  muscular  fibres, 
form  the  uterine  ligaments.  These  ligaments,  with  the  exception  of 
those  from  the  uterus  to  the  sacrum,  offer  but  little  resistance  to  any 
downward  pressure  or  prolapse,  and  are  but  as  guys  to  steady  the 
organ  in  resisting  a  tendency  to  version.  The  action  of  these  liga- 
ments is  aided  by  the  folds  of  the  vagina  about  the  cervix,  which 
acts  as  a  lever  to  maintain  the  axis  of  the  uterine  canal  in  its  natural 
relation  to  the  vaginal  axis. 

We  are  indebted  to  Dr.  Henry  Savage  for  the  demonstration  of  the 
structures  which  really  support  the  uterus  and  oppose  its  displacement. 
To  illustrate  his  views.  Figs.  48  and  49  have  been  copied  from  Plate 
IX.  of  his  work,^  with  the  accompanying  description.  Fig.  48  repre- 
sents a  "  horizontal  section  of  the  abdomen  on  a  level  with  the  upper 
edge  of  the  ilium  on  each  side.  The  uterus,  drawn  down  through 
the  vagina  by  means  of  a  vulsellum  attached  to  its  neck.  Moderate 
traction,  as  much  as  possible  in  the  direction  the  uterus  would  take  in 
the  early  stage  of  ordinary  prolapsus,  was  continued  until  it  seemed 
to  threaten  some  physical  damage  to  the  structures  now  more  strongly 
opposing  its  further  descent.  The  parts  concerned,  exposed  to  view 
as  shown  in  the  figure,  assumed  the  following  relative  bearing: — 

B,  bladder,'depressed  and  compressed  towards  the  pelvis  by  U,  ute- 
rus, which  has  descended  about  an  inch  and  a  half.     C,  utero-sacral 

>  Illustrations  of  the  Surgery  of  the  Female  Pelvic  Organs,  by  Henry  Savage, 
M.D  ,  etc.,  London,  MDCCCLXIII. 


AXATOMTCAL    SUPPORTS    OF    THE    UTERUS. 


289 


ligaments,  having  lost  their  natural  curve  round  the  forepart  of  the 
rectum,  diverge,  and  become  straight  from  being  forcibly  stretched 
between  their  attachments.  0,  alar  mesentery  and  contents  pulled 
forward  and  slightly  depressed.     L,  round  ligament  curved  around 


Fig.  49. 


Transverse  section  of  the  pelvis.     (Uterus  drawn  down.) 

(but  not  on  the  stretch)  in  following  its  uterine  attachments,  g,  ureter, 
a,  spermatic  vessels  somewhat  more  prominent  under  their  peritoneal 
covering.  No  sign  of  strain  whatever,  on  either  the  broad  or  round 
ligaments.  The  utero -sacral  ligaments  having  been  divided  trans- 
versely, the  uterus  yielded  rather  suddenly  about  another  inch. 
Before  examining  the  new  obstacle  which  now  prevented  its  further 
progress,  the  pelvis  was  divided  perpendicularly  and  from  before 
backward." 

Figure  50  represents  the  "  left  half  of  the  pelvis,  and  correspond- 
ing half  section  of  B,  bladder  ;  U,  uterus  ;  and  R,  rectum  ;  P,  pubic 
symphysis ;  0,  ovary  ;  F,  Fallopian  tube  ;  L,  round  ligament.  The 
three  latter  are  still  in  their  natural  relations  with  the  broad  ligament, 
which  is  seen  on  the  stretch,  pulling  strongly  on  the  margin  of  the 
pelvis.  The  bladder  is  drawn  down  with  the  uterus,  owing  to  the 
intimate  connection  between  the  two.  The  rectum  is  not  disturbed, 
the  anterior  layer  of  its  sub-peritoneal  cellular  sheath,  P,  retains  a 
much  weaker  hold  of  the  vagina  than  existed  in  the  case  of  the  bladder, 
19 


290 


DISPLACEMENTS    OF    THE    UTEETS. 


vagina,  and  utenis.  The  uterus  is  seen  half  out  of  the  vulva,  retained 
only  hy  the  broad  ligament,  Tvhich,  vrhen  divided  or  stretched  suflfi- 
ciently,  removes  the  last  obstruction  to  complete  prolapsus  of  the 
or-jan.     After  the  uterus  came  dovrn  a  further  inch,  as  the  result  of 


Fisr.  50. 


J,    1i  J 


Left  half  of  pelvis.     (Cterus  drawn  down. 


di\ading  the  utero-sacral  ligaments,  some  retaining  agent,  other  than 
the  broad  ligaments,  still  prevented  its  arrival  at  this  last  stage,  as 
above  described.  The  obstruction  was  found  to  be  due  to  the  sub- 
peritoneal pelvic  cellular  tissue,  particularly  where  it  surrounds  and  ac- 
companies the  uterine  bloodvessels.  This  tissue  is  here  strengthened 
by  additional  trabecular  filaments,  so  disposed  as  to  support  the 
vessels  and  defend  them  from  the  effect  of  sudden  strain  incidental  to 
the  various  movements  of  the  body,  more  especially  in  cases  of  uterine 
enlargement.  Complete  prolapse  was  eifected  only  after  yielding  of  the 
pelvic  reflections  of  the  broad  ligament.  This  occurred  from  behind  for- 
wards, the  round  ligaments  being  the  last  put  on  the  stretch.  U,  outline 
of  position  of  uterus  before  the  commencement  of  the  experiment." 
The  pelvic  roof  is  thus  described  by  Savage :  "A  plane  passing 


PROLAPSE.  291 

horizontally  backwards  from  just  below  the  sub-pubic  ligament  to  the 
attachment  of  the  utero-sacral  ligaments  at  the  sacrum,  would  indicate 
the  level  where  the  utero-vesical  peritoneal  reflections  pass  from  the 
pelvic  organs  to  the  pelvic  wall.  The  upper  wall  of  the  vagina  is 
firmly  adherent  to  the  base  of  the  bladder  (vesico-vaginal  septum), 
and  to  the  whole  of  the  forepart  of  the  uterine  cervix.  It  follows  a 
slightly  curved  line  from  the  vestibule  to  the  uterus,  and  through  the 
utero-sacral  ligaments  it  is  attached  to  the  sacrum.  When  these 
structures  are  intact,  they  constitute  an  important  line  of  mutual  sup- 
port for  the  vagina,  uterus,  and  bladder  (pelvic  roof)." 

It  is  impossible  to  establish  a  point  which  can  be  accepted  as  the 
normal  position  of  the  uterus  in  health.  This  difficulty  arises  from  the 
fact  that  each  woman  has  her  own  individual  standard,  from  which,  how- 
ever, some  deviations  will  frequently  occur  without  being  necessarily 
the  result  of  disease.  The  uterus  will  change  its  position  in  health  with 
every  movement  of  the  diaphragm,  and  will  be  also  influenced  by  the 
condition  of  the  bladder,  by  constipation,  mode  of  dress,  and  by  any 
temporary  obstruction  to  the  pelvic  circulation.  The  existence  of 
even  a  marked  deviation  is  often  of  little  moment  in  itself.  A  mal- 
position, however,  may  sometimes  render  the  woman  more  liable  to 
suffer  from  some  accidental  complication  from  which  she  might  other- 
wise escape,  were  the  uterus  in  position.  But,  until  the  circulation 
of  the  uterus  becomes  obstructed  from  accident,  and  this  condition  is 
superadded  to  the  displacement,  she  may  remain  long  in  ignorance  of 
her  condition. 

THE  UTERUS  MAY  BE  DISPLACED  DOWNWARD,  TO  EITHER  SIDE, 
OR  IN  THE  UPWARD  DIRECTION. 

The  doiomvard  disjjlacefnent,  or  prolapse,  is  in  proportion  to,  and 
occurs  from,  any  increased  weight  in  the  organ  itself,  or  in  consequence 
of  its  being  crowded  lower  into  the  pelvis  by  some  growth  above.  In 
a  simple  prolapse,  there  may  be  no  deviation  in  the  uterine  axis  until 
the  floor  of  the  pelvis  has  been  reached,  but  any  descent  beyond  this 
point  towards  the  vaginal  outlet  is  always  accompanied  by  a  propor- 
tionate version  of  the  fundus  into  the  hollow  of  the  sacrum. 

When  the  uterus  has  been  crowded  from  the  vaginal  outlet,  in  con- 
sequence of  increased  weight  or  from  pressure  above,  the  progress 
in  the  displacement  will  have  been  similar  to  that  demonstrated  by 
Dr.  Savage.  But  the  same  result  or  a  condition  of  procidentia  takes 
place  more  frequently  from  a  want  of  proper  support  at  the  vaginal 


292  DISPLACEMENTS    OF    THE    UTERUS. 

outlet,  so  that  the  process,  as  described  by  Savage,  is  reversed.  When- 
ever the  perineum  has  been  extensively  ruptured  after  childbirth, 
a  fold  of  the  posterior  -wall,  or  recto-vaginal  septum,  soon  presents  at 
the  outlet  of  the  vagina.  From  the  direction  of  the  rectum  and  the 
curve  in  its  course,  by  which  the  force  is  expended  on  the  weakened 
septum,  this  prolapse  must  be  increased  by  every  effort  at  stool.  In 
consequence  of  this  condition,  and  from  a  want  of  proper  support,  when 
the  woman  is  in  the  upright  position,  the  whole  posterior  wall  of  the 
vagina  becomes  gradually  involved.  The  utero-sacral  ligaments  at 
length  yield,  the  uterus  prolapses  and  becomes  retroverted,  the  anterior 
wall  of  the  vagina  is  dragged  down  from  before  backward  and  turns 
under  the  arch  of  the  pubis,  and  the  procidentia  becomes  complete. 

VERSIOXS  OF  THE  UTERUS  TAKE  PLACE  IX  THE  FORWARD  DIRECTION, 
BACKAVARD  AND  TO  EITHER  SIDE, 

Some  degree  of  forward  displacement,  or  anteversion,  may  be  ac- 
cepted as  a  normal  position.  In  foetal  life,  during  childhood,  and 
after  puberty  in  the  healthy  female  who  has  not  borne  children,  it  will 
be  found  an  exception  to  the  rule  whenever  the  uterus  occupies  any 
other  position  than  one  of  moderate  ante  version. 

Retroversion  is  the  most  common  form  of  uterine  displacement,  and 
is  not  at  all  rare. 

Lateral  versions  are  rare,  seldom  congenital,  and  ordinarily  result 
from  shortening  of  the  broad  ligament  after  an  attack  of  cellulitis. 

Versions  of  the  uterus  may,  in  general  terms,  be  attributed  to  im- 
perfect development  and  to  mechanical  causes.  The  instances  result- 
ing from  imperfect  development  are  comparatively  rare.  A  version 
may  occasionally  result  from  a  defect  in  the  length  of  one  of  the  uterine 
ligaments  by  which  the  organ  is  drawn  towards  the  shortened  side. 
But  practically  almost  the  only  displacement  which  can  be  attributed 
to  a  defect  is  that  due  to  a  want  of  development  in  the  shape  and  size 
of  the  vagina.  In  such  an  instance,  the  vagina  terminates  around  a 
cervix  of  unusual  length,  without  forming  a  posterior  cul-de-sac.  The 
consequence  is,  that  the  neck  of  the  uterus,  being  too  long,  is  neces- 
sarily crowded  forward  in  the  vagina,  in  the  direction  offering  the 
least  resistance,  and  retroversion  follows.  This  result  may  be  con- 
sidered a  mechanical  one,  from  a  congenital  cause  or  defect. 

The  mechanical  causes  of  version  are  easily  recognized  and  are 
brought  into  play  by  the  aid  of  gravity.  As  an  instance,  the  growth 
of  a  fibroid  may  be  cited,  or  an  unequal  increase  on  one  side  of  the 


FLEXURES.  293 

uterus,  from  some  local  obstruction  to  the  circulation,  by  which  the 
organ  -would  naturally  be  tilted  to  the  heaviest  side. 

From  versions  we  naturally  pass  to  the  consideration  of  flexures, 
Avhich  are,  with  a  single  exception,  but  exaggerated  forms  of  the  orig 
inal  displacement,  and  a  result  of  some  local  obstruction  in  the  circu- 
lation of  the  uterus  itself,  or  in  the  surrounding  tissues. 

FLEXURES  ARE  FORMED  IN  THE  CERVIX  AND  BODY  OP  THE  UTERUS. 

Those  in  the  cervix,  it  is  thought,  have  their  origin  about  the  age  of 
puberty  from  faulty  nutrition.  This  form  of  flexure  occurs  at  or  just 
below  the  vaginal  junction,  in  consequence  of  an  undue  length  of  de- 
velopment in  the  cervix,  a  condition  to  which  reference  has  already 
been  made.  The  diameter,  or  rather  the  resisting  power,  of  the  cervix 
will  generally  determine  the  form  of  flexure.  Since  the  size  of  the 
cervix  is  so  out  of  proportion  to  the  capacity  of  the  vagina,  it  must 
either  become  bent  on  itself,  thus  forming  a  flexure,  or  the  neck  must 
rest  in  the  axis  of  the  vagina,  which  will  throw  the  fundus  of  the  ute- 
rus into  the  hollow  of  the  sacrum.  When  the  cervix  becomes  thus  bent 
on  itself,  the  body  of  the  uterus  will  remain  in  position,  or  be  some- 
what anteverted.  But  the  cervix  becomes  ultimately  more  elongated 
and  snout-shaped,  from  being  crowded  forward  towards  the  vaginal 
outlet.  If  the  neck  remains  in  the  axis  of  the  vagina,  and  the  uterus 
becomes  retroverted,  sooner  or  later,  difficulty  must  arise  from  its 
position,  since  it  is  one  likely  to  be  increased  by  constipation  or  over- 
exertion. As  an  inevitable  consequence  of  extreme  retroversion,  the 
circulation  in  the  uterus  must  become  sufficiently  impeded  to  greatly 
increase  the  size  of  the  organ,  and  thus  add  to  the  difficulty.  The 
additional  provocation,  as  an  exciting  cause  of  irritation,  is  generally 
sufficient  to  cause  cellulitis  in 
the  neighborhood,  with  the  efiect 
of  still  more  increasing  the  con 
gestion  and  size  of  the  uterus. 
In  proportion  to  the  descent  of 
the  fundus  into  the  hollow  of 
the  sacrum,  the  cervix  will  be 
pressed  upward  against  the  an- 
terior wall  of  the  vagina,  and 

be  bent  upon   itself  at  or   below  ^^^^oi  a  flexure  of  the  cervix. 

the  vaginal  junction.      This   is 

the  commonest  form  of  retroflexion  (see  Fig.  51),  although  occasion- 


294  DISPLACEMENTS    OF    THE    UTERUS. 

ally  we  find  in  addition  a  flexure  of  the  body  of  the  uterus  above. 
A  flexure  of  the  body  alone  is  rarely  found  until  the  case  has  been 
of  long  standing  and  atrophy  of  the  cervix  has  taken  place,  from 
obstruction  to  the  circulation,  and  that  of  the  body  has  already  begun. 
Frequently  the  flexure  in  the  cervix  is  not  recognized,  and  the  ob- 
server is  misled  by  the  increased  thickening  on  the  posterior  wall  of 
the  uterus,  which  gives  the  impression  to  the  finger  as  if  the  uterine 
body  was  flexed  upon  itself  at  that  point. 

Until  the  treatment  comes  to  be  considered  we  will  not  describe  the 
other  forms  of  flexures  found  in  the  uterine  body,  since  what  has 
already  been  stated  in  regard  to  versions  is  equally  applicable  to  the 
corresponding  flexures. 


ETIOLOGY    OF    UTERINE    VERSIONS.  295 


CHAPTER    XV. 

ETIOLOGY  AND  TREATMENT  OF  UTERINE  VERSIONS. 

Tables  XVIII.  to  XXIII.  inclusive,  showing  the  relations  of  versions  to  menstrua- 
tion, marriage,  celibacy,  frviitfulness,  sterility,  pregnancy,  age,  pain,  etc.,  also 
percentages — Treatment  of  versions. 

It  is  difficult  to  determine  the  class  of  cases  which  should  be  grouped 
together  for  the  study  of  these  displacements.  There  were  eight 
hundred  and  four  cases  of  versions,  or  32.85  per  cent,  of  the  total 
number  of  women  under  observation.  This  number  includes  all  dis- 
placements from  whatever  cause  ;  whether  from  impairment  of  nutri- 
tion or  actual  disease  of  the  uterus  itself — and  these  may  be  called 
original  versions — or  from  the  existence  of  disease  in  the  neighboring 
parts — which  versions  may  be  termed  secondary.  Of  original  versions 
there  were  five  hundred  and  fifty-five  cases,  being  26.76  per  cent,  of 
the  total  number  of  women  under  observation,  and  our  consideration 
shall  be  limited  to  these. 

The  numbers  and  percentage  of  each  displacement  are  shown  in 
Table  XVIII.,  for  the  unmarried,  sterile,  and  fruitful  women,  the 
last  class  being  again  subdivided  into  women  who  had  never  mis- 
carried, those  who  had  borne  children  to  full  term  but  also  mis- 
carried, and  those  who  had  miscarried  and  never  gone  to  full  terra. 

The  number  who  menstruated  for  the  first  time,  between  the  ex- 
treme ages  of  ten  and  twenty,  are  also  given,  with  the  average  age  at 
puberty  for  each  class,  and  the  average  age  at  marriage. 

These  tables  are  given  as  part  of  the  history  of  displacements,  but, 
however  useful  they  are,  we  cannot  accept  deductions  from  them  as 
conclusive,  until  confirmed  by  more  extended  observations.  They  seem 
to  indicate  that  sterile  women  menstruate  for  the  first  time  later  in 
life  than  any  other  class  ;  and  that  fruiful  women  who  miscarry  begin 
to  menstruate  later  than  those  who  go  to  full  term.  For  it  is  shown  that 
those  who  always  miscarried  approached  nearer  than  any  other  the 
averages  of  the  first  menstrual  aore  of  the  sterile.  Those  who  habitu- 
ally  miscarried  show  also  a  larger  proportion  of  retroversions  than 
those  who  have  borne  children  to  full  term.  On  the  other  hand,  it 
will  be  seen  that  childbearing  seems  to  increase  greatly  the  propor- 


296      ETIOLOGY    AND    TREATMENT    OF    UTERINE    VERSIONS. 


9q?  oi 


■pmAS. 


rt   P  o  © 
O   rt   o   c 


Hl^ 


cS   p  o   ® 


>1  (M  W 


•on^o^g 


6= -^55 


CO  c^  o  o 


c>  o;      -i"  o 


=  a  oi 
o  o  j5 


CI  a 


>-  o  t! 


Ci    fe    CD   o 

fiat-' Eh 


m   3  a>  ■" 
.2  d^  a 


CO  CO     -co 


cj    p   <E   <D 

^ .'-:  ^  ^ 


k-    i£^ 


FREQUENCY    OF    VERSIONS. 


297 


tion  of  ante  versions.     The  number  of  lateral  versions  is  too  small  to 
warrant  definite  conclusions  concerning  them. 

Table  XIX.  presents  a  summary  of  all  classes,  as  given  in  Table 
XVIII.  If  Ave  accept  the  data  furnished  by  Table  III.,  page  166,  as  to 
the  relative  proportion  of  the  unmarried,  sterile,  and  fruitful,  it  -will 
be  seen  by  the  table  before  us  that  neither  class  is  more  liable  to 
suffer  from  versions  than  the  other  two.  In  the  last  column  to  the 
right  of  Table  XIX.  is  given  the  proportion  of  each  class  of  women 
who  suffered  from  versions.  By  comparing  these  with  the  relative 
proportions,  as  given  in  Table  III.,  it  will  be  found  that  they  are 
almost  identical. 


Table  XIX — Frequency  of  Versions  among  the  Unmarried, 
Sterile,  and  Fruitful. 


u 

cS 

o 

bo 

"a 
0 

<B 

13 
a 

bo 

d 

3 

to 
® 
Ph 

0 

<B 

bo 

U 

Summary. 

13 
5 

p. 2 

c 

t3 

03 

'55 

Unmarried. . .  . 

34 

36.17 

5o 

58..U 

2 

2.12 

3 

3.19 

94 

Percentage. . 

14.40 

18.64 

16.93 

Sterile 

57 

36..M 

87 

.55.76 

3 

1.92 

9 

5  76 

156 

Percentage. . 

24-15 

29.15 

28.10 

Fruitful 

145 

47.57 

153 

50.16 

1 

.32 

6 

1.96 

305 

Percentage. . 

61.44 

51.86 

54-55 

Total      

236 

42.52 

295 

53.15 

6 

1.08 

18 

3.24 

555 

Percentage. . 

Table  XX.  is  of  interest  in  pointing  out  that  there  was  no  special 
indication  given  at  puberty  of  the  existence  of  disease  among  those 
women  who,  in  after  life,  suffered  from  version. 

Table  III.,  page  156,  which  has  been  already  referred  to,  gives 
also  the  proportion  of  women  who  were  regular  from  the  first,  of  those 
who  became  regular,  and  of  those  who  were  never  regular.  It  also 
shows  that  a  large  proportion  of  women  commence  their  menstrual  life 
in  good  health,  and  the  percentage  (72.33)  given  is  doubtless  cor- 
rect. By  comparing  Table  XVI.  and  Table  III.  a  remarkable 
coincidence  may  be  noticed,  the  percentages  for  the  several  classes 
in  Table  XVI.  being  almost  identical  with  those  taken  on  the  total 
number  of  all  women  under  observation. 

The  percentages  for  retroversion  differ  slightly  from  the  general 
percentages  indicated  in  Table  III.,  and  show  that  of  women  who  in 
after  life  suffered  from  retroversion  a  larger  proportion  were  regular 
from  the  first,  leaving  a  smaller  number  for  those  who  became  regular 


298      ETIOLOGY    AND    TREATMENT    OF    UTERINE    VERSIONS. 

afterwards,  or  who  were  never  regular.     The  deductions,  therefore,  to 
be  drawn  from  these  figures  are  greatly  in  favor  of  the  supposition 
that  retroversions,  as  a  rule,  have  their  origin  at  a  later  time  in  life. 
The  only  point  to  be  noted  in  regard  to  lateral  versions  is  that  the 
large  proportion  of  those  Avho  suffered  from  them  were  sterile. 


Table  XX Condition  of  Menstruation  with  Versions. 


Condition  of  menstruation. 

Unmarried. 

sterile. 

Fruitful. 

Total. 

m 

fi 

.2 
"tn 

> 

""  Regular  from  the  first .... 
Percentage    

Regular  afterwards 

Percentage    

Never  regular 

Percentage     

25 
69.44 

5 
13.88 

6 
16.66 

40 
76.92 

8 
15-38 

4 
7.69 

95 
71.96 

23 
17.42 

14 
10.60 

160 
72.72 

36 

16,36 

24 
10.90 

Total 

L              Percentage 

36 
16.36 

52 
23-63 

132 
60.00 

220 

P 

.2 

> 
p 

'  Regular  from  the  first  .... 
Percentage    

Regular  afterwards       .... 
Percentage    

Never  regular 

Percentage    

32 
80.00 

4 
10.00 

4 
10,00 

51 
83.60 

7 
11.47 

3 
4.91 

104 
83.20 

14 
11.20 

7 
5.60 

187 
82.75 

25 
11.06 

14 
6.19 

Total 

Percentage    

40 
17.69 

61 
26.99 

125 
55-31 

226 

.2 
»>  - 

'  Regular  from  the  first  .... 
Percentage    

Regular  afterwards       .     .     .     . 
Percentage    

Never  regular 

Percentage    

1 
100.00 

8 
80.00 

2 
20.00 

2 
40.00 

2 
40.00 

1 
20,00 

11 
68.75 

4 

25.00 

1 
6.25 

Total 

Percentage    

1 
6.25 

10 
62.50 

5 
31-25 

16 

It  is  shown  by  Table  XXI.  that  of  those  who  had  anteversion  and 
suffered  from  pain  at  the  beginning  of  the  flow,  75.86  per  cent.  Avere 
fruitful  afterwards.  The  only  explanation  which  can  be  offered  in 
the  present  state  of  our  knowledge,  is  in  the  supposition  that  flexure  of 
the  cervix  at  first  existed.     We  shall  see  hereafter  that  pain  at  the 


CONDITION    OF    MENSTRUATION    WITH    VERSIONS. 


299 


s 

^ 


8 

a 


s 


ts 


^ 


t^ 


■^  . 

^  : 

•}U83  JO  J 

;    ; 

rt 

" 

Eh 

•jAog  JO 

^ 

0 

c=.!3 

".•5 

00 

^ 

UliJHoi  puB 

:o  0 

oc  t- 

§i5 

■^::^ 

^■^' 

i^lrf 

BOSBO  JO  'OJJ 

s  • 

R  • 

M        ■ 

00 . 

8  • 

^      . 

t^    . 

R  : 

o5 

3 

•jneo  J9J 

M         • 

rn    ■ 

CO     • 

a 

" 

CO 

Vi      ' 

•< 

a 

•Mog  JO 

0 

0 

*4« 

a> 

0 

^ 

e^ 

-»" 

Bi 
id 

u 

fn 

TIJ^uoi  puB 

•><< 

<d 

QC  01 

v.  to 

C5  q 

to 

"^  ■* 

-H  to 

SasT!3  JO  -ojj 

R   • 

?r.    • 

x^  • 

s  • 

8  • 

'O      , 

N      . 

8  : 

< 

•}II8D  J3  J 

0  : 

t^  ; 

^  ; 

N      '■ 

vS  : 

VO     ; 

-  : 

^ 

•Ai.og  JO 

0 

C 

0 

- 

cc 

v: 

0 

OQ 

i(iSna[  puB 

m  0 

00  0 

t-^ 

CO  cc 

to 

H 

B98'B3  JO  ■0>I 

0    . 

R^  • 

CO      . 

a  • 

•?na3  J9j; 

t^   ; 

c^  1 

■^  '. 

•0    • 

^ 

d 

cc 

•^Og  JO 

0 

0 

0 

■qiSuai  pni! 

m  0 

ci  0 

10  OD 

0 

0 

88B-B3  JO  -0^ 

t^  ! 

•jnaD  j8£ 

ci    ■ 

rt 

0 

•Aiog  JO 

■ra 

(^ 

0 

0 

0 

m 

5-1 

H 

TH3n8x  puB 

0  0 

S^ 

t^  c 

p  CJ 

55:;; 

^i< 

S  'l* 

A 

sasBo  JO  -Oij 

M 

0    . 

t^  , 

ir,    , 

VO     . 

B 

^ 

•}uaj  jaj 

w     • 

M    ■ 

in    • 

3 

VO      • 

-J-  ■ 

S 

u 

•iivog  JO 

CO 

en 

CO 

-^ 

^ 

e-i 

p^ 

mSaai  pn^B 

<N  q 

tOf-H 

1-  c 

T)< 

^  13 

s« 

•< 
t3 

0 
H 

%    • 

t^    . 

■S  ■ 

0    . 

TC*     ■ 

0?    ■ 

CO     • 

t^   . 

K 

■JTlaO  J9  J^ 

O'    • 

M       • 

v^     • 

ci     ■ 

r^    • 

« 

^ 

-    ' 

VO     • 

"   ■ 

n    •       ! 

-^     • 

'»■  ■ 

" 

« 

0 

^ 

^ 

•Avog  JO 

^ 

r^ 

CO 

0 

r^ 

is 

K9S'B3  JO  -Oil 

-"o 

■^^ 

I--  0 
■"  0 

'^  -t 

'--^- 

H 

N 

C4 

CO      . 

R  • 

0     . 

•-'     . 

•;u80  ja,j 

in    • 

4     . 

VO      • 

t^    • 

0 

'-'    ' 

M                     1 

H       • 

c<     • 

•^ 

'^ 

1 

•Ai.og  JO 

00 

(N        1 

0 

cc 

M 

SaS'BD  JO  -0)1 

0 

cc  m 

^0 

0 

to  to 

s::;; 

«^ 

^  : 

^  : 

o    • 

■S3     . 

• 

•a    • 

£>. 

•S   >. 

X 

tn  S>% 

5;. 

>-, 

a  ^ 

S^^ 

•TS 

5^ 

0^ 

-3 

-d 

3^ 

iod 

^.^ 

'^  d 

ir  d 

E:.3 

.if 

£  d 

a  ^ 

-1 

^  ^ 

1? 

=  ? 

0 

%  & 

tea 

.=  =3 

13 

d« 

6f.a 

^=3 

M- 

c« 

tfJO 

'^. 

^^ 

^■■■"^ 

0 

^^ 

.iij 

e  5 

" -d 

^■^ 

d5 

0^ 

I^  ^ 

d  to 

?? 

d  to 

■5  l" 

0  ^ 

"5  d 

-3  d 

c5  d 

-  I" 

E.g 

■=  r 

5  «, 

=  1) 

c  — ■ 

"5  s> 

E-r 

p.  ID 

P.^0 

~  c3 

^^ 

P.=u 

—   c3 

?ii; 

3S 

^^ 

h< 

r*  > 

"   > 

fe<: 

&-<i 

?  ■^ 

t.<J 

E^O 

V — 

-9nO!8J9A9)n 

V 

•snoisjaAOna! 

I 

300 


ETIOLOGY    AND    TKEATMENT    OF    UTERINE    VERSIONS. 


•jaqcanu 
■[■Bjo}  no 


•snoi8.T9A  JO 
•0|i  x^:>ox 


l-H  CO 


CI  -^        O  Ci 


•BSS'BD  JO  "Oil 


•}neD  ja  J 


•S98H0  JO  •OJJ 


■?n8o  jej 


■SSS'BD  JO  'O^ 


•}U93  J9  J^ 


•^05  JO 
S9«-B0  JO  'O^ 


c  o 


00         i-H  CO 


CO  CD         Ci  i-H         «  10 


•jneo  jaj; 


'M.OQ  JO 

tljSnex  pn'B 
sas'EO  JO  -Okj 


•;n90  ja£ 


•jMog  JO 
sas'Ea  JO  -o^i 


•?xi93  aa  J 


•4100   JO 

■qjSuaX  pn'B 

SaBBO  JO  'O^J 


w;  c^      t^t^ 


5?. 

I  I 


't3 

tc'o 

.2  J 

5  '5) 

•c  a 

^■5 


£  to 


s- 


■BUOISJjAOJUV' 


55  CO 

iCO        CO  o 


CO  t- 


<M      . 

Oi      . 

0      . 

C-J      . 

to    . 

o>    ; 

CO     • 

IC     I 

^  : 

0 

0 

CJ  0 

CO  CO 

•rr 

c^ 

\o   ; 

W  10        Tj*  t^        00  t^ 


e^  O       rH  o       ■>*  t 


rIO        «0 


eq  o     C5  o 


•r*  ^ 


cJ  r' 


1^ 


o   > 
E-<1 


•9U018jeA0Jjaj£ 


-  — .  00 

'.  't^  -« 

,    O  00 


-M<N    ^    O    ^   ^ 


.r  a 


to 


^  -i  © 

^  s  p. 

■E  -e  '^.  ^  Q  -TS 

<^    -^  ^   X   O  o 
"^  O   O  ^  ""  t-' 

c  ^  S  .2  i  ^ 

o  -  -^  ~  ^  a 

c'  £  "^  2  c  •:? 

t-  =  o  TJ  =  3 

p-  £  --  S  ■-=  t* 


t-.9  a  a  ^'^ 
X  2  =.a=  -, 


T  "S  "-  o  =3 


;-^?1a3 


Ea 


!xa  ^v< 


•2  -    2  a  i  ■" 
to^5  •--  cj  :o 


i.^-2a. 


"S  o  "^  ""  •--  o 

.2  -  =  £  s  o 
-  <  ©  w   C  J3 

e.     ",^  g  — 

■"  2  ©  cc  p  a 

V  o  — "*  c  't, 


•5  _rc^  c;  "^  ^ 

=  J.  .=  r  -  a 
tfS  tea  0  a 
■      S'Sj 


r  ©  ?i  ^j 


r  © 

■"' a5  = 

a  ''^      T-^ 
©  ci  -tj  ..  Ui- 

s  :-  ■*  ^^.2  S 

^  ^  o  a  «  "    . 

=  ,^_^.25  5.2. 

c  "^  d  ^c  3  a 

te  a  ^  5    .  o 
-£:  o  OS  P<n^  w 


CONDITION    OF    MENSTRUATION    WITH    VERSIONS.         301 

beginning  of  the  menstrual  flow,  but  which  ceases  as  soon  as  this  becomes 
established,  is  almost  characteristic  of  this  form  of  flexure.  Observa- 
tion has  shown  that  with  elongated  cervix  the  position  of  the  uterus  is 
frequently  changed  from  an  anteversion  to  a  retroversion,  before  the 
flexure  has  become  permanent.  We  have  learned  also  that,  with 
uncomplicated  version  of  the  uterus,  if  dysmenorrhoea  exists,  the  pain 
is  experienced  almost  without  exception  during  the  time  of  the  flow. 

Fifty-two  and  a  half  per  cent,  of  those  who  at  puberty  had  pain 
during  the  flow  were  sterile  in  after  life.  By  reference  to  Table  V. 
page  157,  we  will  see  that  this  is  almost  the  same  proportion  as  was 
found  for  sterile  women  on  the  general  average.  In  other  words,  it 
was  found  that,  of  all  women,  who  at  puberty  had  suffered  pain  during 
the  flow,  more  than  half  proved  to  be  sterile  in  after  life.  As  this 
average  is  rather  less  than  the  general  one,  we  cannot,  from  the  char- 
acter of  the  pain  alone,  accept  it  as  evidence  that  the  version,  if  it 
then  existed,  was  the  cause  of  the  dysmenorrhoea. 

Sixty-eight  and  sixty-three  one-hundredths  per  cent,  of  all  women 
who  had  anteversions  in  after  life  had  been  free  from  pain  at  puberty, 
and  of  these,  66.88  per  cent,  were  fruitful. 

It  was  found  that  the  proportion  of  fruitful  women  who  had  pain  at 
the  beginning  of  the  flow,  and  suff"ered  in  after  life  with  retroversion 
or  anteversion,  was  greater  than  for  either  the  sterile  or  unmarried. 
For  those  with  pain  during  the  flow,  the  proportion  was  greater  for 
the  sterile  and  unmarried,  although  the  pain  was  not  so  great.  In  a 
similar  manner,  it  will  be  seen  that,  of  those  free  from  pain,  the  pro- 
portion was  greatest  for  the  fruitful  woman.  It  will  be  noticed  that 
75.66  per  cent,  of  those  with  retroversion  had  no  pain  at  the  begin- 
ning of  menstrual  life,  this  being  a  much  larger  proportion,  under  the 
same  circumstances,  than  was  found  even  for  those  having  antever- 
sion. Only  15.04  per  cent.  suflFered  pain  during  the  flow  at  puberty ; 
and  finally  82.75  per  cent,  of  these  cases  were  regular  without  delay. 
These  facts  are  additional  indications,  in  support  of  the  supposition 
which  has  already  been  advanced,  that  retroversions  take  place,  as  a 
rule,  after  puberty  ;  it  being  well  known  that  when  a  retroversion  is 
detected  in  after  life,  painful  menstruation  is  then  the  rule.  In  fact  with 
these  cases  suffering  from  retroversion,  the  proportion  of  those  with 
pain  during  the  flow  is  far  greater  even  than  that  given  for  the  number 
who  menstruated  for  the  first  time  without  pain.  It  cannot  be 
supposed  that  retroversion  could  exist  so  many  years  without  having, 
as  a  consequence  of  the  malposition,  a  condition,  or  disease,  established 
which  would  have  sooner  called  for  relief.     This  Ave  must  admit  or 


302      ETIOLOGY    AND    TREATMEXT    OF    TTERIXE    VERSIONS. 

hold  that  the  displacement  is  in  itself  of  little  consequence  unless 
some  othei'  condition  coexists. 

The  length  of  period  at  and  after  puherty  is  also  shown  in  Table  XXI. 
For  both  forms  of  version,  T\'ith  pain  at  the  beginning  of  the  flow,  the 
length  of  period  was  less  than  that  shown  by  Table  II.,  page  155,  for 
the  general  average.  When  pain  existed  during  the  flow  the  average 
duration  was  much  less  for  anteversion,  and  a  trifle  more  for  retro- 
version, by  the  same  standard.  For  those  women  who  did  not  suffer 
pain,  these  averages  were  reversed.  On  all  cases  of  anteversion  the 
average  duration  was  greater  than  the  general  one  taken  on  all  women 
under  observation,  while  the  reverse  was  true  for  the  total  number  of 
retroversions,  and  for  each  class  of  women  with  retroversion,  except 
the  fruitful,  with  whom  the  duration  of  the  flow  was  longer. 

On  account  of  the  small  number  of  lateral  versions  (sixteen)  they 
were  not  included  with  the  other  displacements  in  Table  XXII.  Any 
deductions  drawn  from  statistics  based  on  so  small  a  number  would  be 
of  little  value  if  they  did  not  fully  confirm,  as  they  however  do,  those 
already  drawn  from  a  study  of  the  other  displacements.  Thus  of  the 
sixteen  women  with  lateral  version  one,  or  6.25  per  cent.,  had  pain  at 
the  beginning  of  the  flow  ;  four,  or  25  per  cent.,  during  the  flow  ;  and 
eleven,  or  68.75  per  cent.,  were  free  from  pam  at  puberty.  Eleven, 
or  68.75  per  cent.,  were  regular  from  the  first ;  four,  or  25  per  cent., 
were  so  after  a  certain  time;  and  one,  or  6.25  per  cent.,  was  never 
regular.  The  average  length  of  menstruation,  with  pain  in  the  begin- 
ning of  the  flow,  was  four  days  ;  with  pain  during  the  flow  four  days  ; 
and  for  those  who  were  free  from  pain  4.90  days.  Those  who  were 
regular  from  the  first,  menstruated  on  an  average  5  days,  and  for 
those  who  became  regular  afterwards,  the  average  was  only  3.50  days, 
much  less  than  that  for  the  same  conditions  with  either  of  the  other 
forms  of  version.  Five  days  was  the  average  length  for  the  only  woman 
who  was  never  regular,  and  the  average  for  all  cases  of  lateral  version 
was  4.62  days.  Of  the  total  number,  one,  or  6.25  per  cent.,  was  un- 
married ;  eleven,  or  68.75  per  cent.,  Avere  sterile;  and  four,  or  25 
per  cent.,  were  fruitful  in  after  life. 

Table  XXII.  is  designed  to  show  the  after  changes  in  menstruation, 
particularly  as  to  the  length  of  flow.  The  first  impression  is  one  of 
surprise  that  the  averages  on  the  total  number  should  exhibit  so  little 
change  in  the  length  of  the  flow,  seeing  that  the  extremes  are  two 
and  ten  days.  If  we  consult  Table  XII.,  which  shows  the  after 
changes  in  menstruation,  and  which  was  made  up  from  all  the  women 
under  observation,  without  reference  to  versions  or  to  disease,  the 


CONDITION    OF    MENSTRUATION    WITH    VERSIONS. 


303 


' 

•JUOO 

^  :  : 

<o    .    • 

to    .    . 

s  • 

S  :  : 

Cl      .     . 

S  :  : 

to    . 

5 

5 

jej 

OS    ;    ; 

i  :  : 

00    ;    ; 

s  •• 

■o    ;    ; 

§  : : 

i  ■  ■ 

^  : 

o 

in-< 

Cl  r^ 

M   CO 

'O 

«^S 

mr- 

-H-l- 

^ 

3 

ti 

•SOSBO 

t*  "*i* 

^  ^  CO 

r-    0\=> 

-!•<» 

CO  "^n 

CO  ^  •"• 

'j:,  o 

•a  m 

JO  OK 

ONf' 

ri    «■  ,jj 

t-^ 

00  <» 

to« 

o     .     . 

O     .     . 

N    .    , 

^ 

CO 

•o    .    . 

^ 

,, 

a  c3 

u 

•?noo 

x    .    . 

Cl     ■ 

to  :  : 

C4      '     I 

r—^       . 

_d 

jaj 

n*     •     ■ 

^'      •      ■ 

!3    •   • 

»'    ; 

S  ■  • 

00     •     • 

•d    ;    ; 

to'    ; 

tc 

0  '^ 

o  — 

rOCO 

CO          i 

c^o 

r-to 

ri4-5 

CO 

s  ^ 

s 

•«osi;d 

CO  o*-= 

<M^.  = 

t,  r-.-r 

«to 

fH    0  ° 

«    NtO 

t~  'H  '^. 

-d  o 

^ 

JO  -OK 

VO^ 

CO  co' 

r-i  CO 

OvCO 

I^M 

CO-f 

-^  -r 

11 

"^      .      • 

O      ,      . 

CO      .     . 

-*      . 

CO      .      . 

o     .     . 

CO 

CO 

o 

O      '      ' 

o    *    • 

?■  :  : 

CO  :  : 

CO    ;   ; 

CO     •     • 

g  '■  '• 

c5   ■ 

9 

fO»0 

C3  8S 

O  CO 

CO 

(M'S'o 

t^o 

f^.t'- 

CO 

o 

•sas'BD 

(,.0  03 

oto 

CO    CO 

(^Q    Cl  t~» 

CO  05 

«1 

<-i 

JO  "OX 

rOTjI 

0  -)< 

"  VO  -»< 

-.o^ 

t».iO 

r?,iO 

^^-,; 

'»-r 

., 

"^      •      • 

^ 

c     .     . 

o     .     . 

o 

CO     . 

K 

^ 

•a 

•^nao 

ci  :  : 

c      .     . 

Cl  : 

c     .     . 

CO  :  : 

o    . 

C 
>5 

a 
o 

o 
o 

JOJ 

n    •    ■ 

ci    •    • 

o 

o    ■    • 

-r    •    • 

■*    • 

a 

(^ 

t^o 

t^ 

t^to 

00  1-1 

rH?S 

C5 

iJ) 

3 

•B9SB0 

o>s  = 

t,  r;,o 

Cl  -i; 

j^  VO  CO 

t,    u-lt- 

r-   Cl 

13 

a 

JO  -Oil 

lAlO 

"'   4-v:: 

CO  lo 

c^--6 

cico 

c^  t^-; 

—  o 

a 

*t*    .    . 

-*"    . 

o     . 

o 

o 

•)TI80 

«  !  ; 

t^    '    • 

Cl  :  : 

o     , 

»c    '    '. 

*-;     '.     I 

-".    •    ' 

"1    • 

•< 

^ 

Md 

^  •  • 

CO     •     • 

T{   *   • 

c<i    • 

is   •   • 

cl    \    ; 

V.   '■  '■ 

^   ■ 

^ 

o 

5 

a 

H 

inCi 

>-.  CO 

roQO 

C5 

rom 

lOO 

MCI 

CO 

t2 

"SaSTiD 

t,  -« 

to  VO  to 

IN  ".  =^ 

»-\  O 

CO  t-« 

o  «■>: 

o  0.'-. 

CO  to 

o 

.3 

JO  -ojj 

f-i  >o  o" 

■-1  4-'a 

«    ds^ 

too 

eo  ci-11 

■^  co-t 

m-^ 

i^ 

^0 



< 

^ 

■M 

o    ,    . 

t^    .    . 

o    . 

t- 

CO      .      . 

o     .     . 

o     . 

c* 

c 

■}U0.1 

■'*      .      • 

^     .    . 

o     . 

CO      I      I 

CO      .      . 

'-"^      .     . 

cl     . 

t- 

"   M 

X 

JSd 

CO    ;    \ 

ci    ;    ; 

ci    •    • 

s  • 

s    ■   • 

CO     ;    ; 

Cl    ;    ; 

!::  ■ 

a: 

2  ^^ 

p  5 

"a 

s 

C-3 

CO 

t^o 

00  o 

■*-)< 

o 

o  o 

toco 

mo 

CO 

•sas'BO 

-1<  ^=^ 

<N  ■?=; 

t,CO,-H 

"1"  °.^-: 

t,  t^-ci 

•o  ".°. 

coc-. 

JO  -Oil 

0-3< 

ineo 

moi 

i-^co' 

w"" 

co'q' 

MCI 

r-c, 

§i 

•S  3 

d''' 

to     . 

C5       .       , 

o     .     . 

•}U0O 

to  ;  . 

t^     .     . 

t^     .    . 

to  :  ; 

o     .     . 

C.      I 

^  S 

©" 

■lad 

t-  *  " 

CO     ;     ; 

CO    ;    ; 

CO       * 

rxj      '      * 

to*     •     * 

10      •     " 

co'    ; 

a  3 

o 

r-l 

*"* 

r-l       •      • 

r-l 

"S'-S 

o 

0  m 

oto 

O  CO 

00  o 

ir,o 

ID  to 

a 

a 

ir< 

•SOSBO 

en  o^n 

CO  qta 

O    0  CO 

Cl  <'; 

C^    rr.q 

o  ^to 

to  -:'-= 

CO  to 

JO  -ovi 

\ritA 

lot* 

s>^ 

f-^  50 

u-.t* 

%'° 

VO  CO 

1-  to 

^ 

« 

CI      . 

CO      . 

o     .     . 

O      .      . 

«v-« 

•;n90 

i-^     .     ' 

c^      '      I 

tr-     .    * 

o     ,     . 

cc  : 

o 

^ 

jaj 

c/j'      *     • 

CO     •     • 

c"     •     ' 

^     ■ 

CO 

^    '.    '. 

Cl       *      ' 

CO       * 

e£ 

o     •    • 

t^    •    • 

to     •    • 

-o     • 

% 

B 

a 
o 

o 

OS 

0C5 

c  o 

Cl 

to  o 

«co 

-  m 

^ 

1^ 

•S3SBD 

o  o"^. 

r-l    ""O 

ciO-; 

O  r-l 

t-'Oi- 

CO  *^co 

<a  T'"--. 

-r  to 

^ 

JO  -Oil 

r-l    ,A>0 

r-"    tiio 

■^  O 

r-ivo-* 

■-loo'Tli 

«m^ 

^  -^ 

r3 

f; 

^ 

^ 

fe 

1 

t^ 

^ 

:  ^ 

^ 

O 

55 

o 

O 

a 

o 

o 

ta 

iti 

o 

Q 

%-! 

*«-i 

tt_ 

«fc-« 

«fcH 

t*- 

•  1— 

-*« 

h 

^ 

o 

00 

o 

o 

'_' 

« 

o 

^ 

o 

^ 

:  o 

o 

i| 

g  ^"to 

1  g"-^ 

1  M 

!          -^  a 

-^   3 

**-  a  o 

t—    C   CJ 

^ 

O    c  '"' 

o  S  — 

o  5"^ 

c  •-* 

!     «  S  — 

O    o  — 

O    O  '"' 

o  — 

t,  o  o 

t.  "  s> 

u  o  o 

^  o 

t.  F  o 

^,  P  o 

t-   o 

S  £  ^ 

o  i;  to 

o  -  to 

c  to 

S  'r  to 

S  3  to 

^o^t 

o  tc 

c 

^.'^  =3 

,=  e 

-S,®   eS 

.a  s 

o  ^ 

a       o 

g'^  i 

c  S 

S-  S 

S~'  s 

S'"'  3 

S  3 

s       >■ 

3        !» 

3        !► 

3  > 

"       > 

3        > 

S         t» 

—  :^ 

5"^ 

tC3 
C  — 

S5      <! 

iz;    <! 

^       <1 

fc< 

>s     -^ 

k:     < 

^     -:: 

15  <! 

<D 

to 

c 

3 

o3 

5 

II 

g 

3 

c2 

(-1 

o 

> 

a 

-2 

3 

Eh 

a 

s 

£ 

E-1 

& 

03 

[i< 

^ 

m 

Pi 

^ 

ji 

/ 

r 

H 

•saoisjOAainv' 

•sao|SjaAoa}Oij 

[ 

304 


ETIOLOGY    AXD    TREATMENT    OP    UTERINE    VERSIONS. 


6 


B 
< 


-rt     ■ 

- 

d 

(N 

« 

o 

>o 

>o 

C 

- 

"         O 

"      •» 

iq  <0 

-*   ^ 

="    ^ 

S      -o 

S^ 

t. 

O      .      . 

CO 

j_, 

CO 

_p 

A 

CO  :  ; 

^^     . 

o  .  : 

O      . 

^ 

-tsj 

i-H      "      • 

r-       ■       • 

CO     •     • 

CO      * 

cq    ■    • 

00     •      ' 

>. 

o 
Eh 

•sas'BO 

►-0 

Tj<   <»   O 

^f^^ 

CT   -fc» 

^-^ 

OO 
113    t^oo 

«Kg 

CO  o\c6 

>* 

jo-o>i 

o  « 

<-l     -i^ 

^    0\CO 

CO  CO 

T(N 

>-    N  CO 

'-'   «  CO 

"co 

d 

•?n90 

O      .      . 

C5      .      . 
O      .      . 

o    . 

<s 

■13d 

Ci      •     ' 

c;     •     • 

oo     ' 

A 

Z 

•ses'EO 

mo 

^    rpo 

\D  O 

eqvoo 

o 
coO 

o 
a 

'-' 

JO  -o^i 

miM 

S--^ 

■* 

- 

•a 

■jnsD 

»c     .     , 

o    . 

H 

m 

"d 

"^     ;    ; 

(M    ; 

S5 

JO  •o.\r 

0  « 

o 

CO 

iz; 

'a 

-^ 

o 

•a 

•^nao 

g     ;     ; 

o    .    . 

CO      .      . 

<»    . 

A 

•tad 

2  :  : 

CO      •      • 

o    •    • 

o    ;    ' 

<D 

o 

•ses'EO 

N  O 

oo 

0  o 

ino 

H 

o 

^     IH   O 

o  t^.o 

05    ^t>. 

lO  t^to 

oo  o\co 

-f  •-' 

1-1 

JO  -on 

2" 

■-1   0  c^ 

"-I  t^eo 

CO  CO 

Z"^ 

r-'     (N  CO 

"-I     N^CO 

^vi 

IM     .     . 

o     .     . 

■«o    .    . 

o 

K 

0-^      .     . 

o  !  ; 

I>    . 

f^  - 

^ 

-lOd 

eq    ■    • 

t-     *     • 

s  :  : 

la    ■    • 

CD      *      ' 

CO      •      * 

^ 

o 

•SOSBD 

int~ 

u-,(M 

\o  t^ 

Ol 

■*CD 

'£ 

00    M  CO 

C3  T"^ 

t-  r"-"^ 

*t<  o 

CO    C^CO 

^    OMq 

,-,  t^o 

O 

iz; 

JO-OM 

00  CD 

0  to 

VO 

^co 

CT>0 

N  lO 

cq    t^t^ 

VO 

COc^ 

e3 

•}U80 

S  :  : 

S  :  • 

o    . 

o     .     . 
o     .     . 

§  :  : 

t'  r  ; 

CO     . 

O 

c3 

J3d 

1— 1     '     • 

^  •  • 

o    •    • 

CO      * 

K 

3 

'"' 

■"I 

■"•    ' 

■< 
15 

■S89B0 

^8g 

9^ 

cc  c  C-: 

c 

0  CO 

CO  qcu 

,-1    0  o 

0  o 

r-H    °  = 

o  oo 

■^ 

JO  -o^sr 

xncrs 

U-.  CO 

■o 

CD 

,rt 



N 

'^ 

«  r-H 

s= 

•^noo 

o     .     . 

en  : 

.    .    . 

o     .     . 

N      .      . 

!>.      . 

» 
S 

i 

® 

JSd 

iM    ;    ; 

t^  .'  r 

to   ; 

o    :    ; 

o    ; 

0 

k1 

■SQS'Ba 

r-l     '?'^ 

VO  O 
IMVO-C 

co== 

f^.O 
rH    fO 

VO  O 

^ 

JO  -oisi: 

rot- 

^g'" 

CO 

'm" 

o 

<§ 

<*-« 

O     .     . 

00      ,     , 

tc     .     . 

O!       . 

,__, 

Cl 

o 

•a" 

CO      .     . 

c     .     . 

o      .     . 

t-      ,      ; 

f— 1     , 

^ 

•lOd 

t^    ;    ; 

Si    •    '• 

s  •  ■ 

■T       ; 

c    ;    ; 

o    •    • 

s  •  • 

-f    ' 

to 
a 

ri 

u 

>A 

a 

•83SE3 

H   00 

cc  ^  to 

t^CD 

o 

■^co 
m  0  o 

c^g 

co^Sco 

o 

JO  -OX 

CO  !0 

"  O 

..    OJCO 

roo 

00  o 

"Cg_CO 

C^  CO 

^ 

^ 

^ 

^ 

& 

^ 

^ 

^ 

o 

o 

o 

o 

o 

S 

« 

« 

o 

w 

aa 

<a 

« 

P. 

%-< 

tt-f 

«w 

tM 

..-1 

»M 

V-. 

t, 

m 

09 

00 

at 

o 

(C 

X 

o 

oe  O 

S  OA 

s  <=>^ 

g  cd 

'-  a 

M    O-^ 

S    <B^ 

®j3 

(9 

*-  a 

"^    CI 

"-5  a 

s^^ 

g|3) 

gbi 

<^H  c  a> 

<"  a  o 

<-    o 

»-.  a  o 

O 

O— c 

o  g- 

o   o  — 

m 

III 

tH    £   o 

fc,    U    OJ 

o  g  ho 

t,    U    ID 

PI 

f-'  y  ° 

o  J-  to 

J.S^ 

11)   bo 

03 

a'-'  s 

S"^S 

a-s 

£  5 

a-^g 

a  s 

3        k 

s      > 

3        > 

3   > 

3        > 

3        !> 

3        >• 

d 

iz;    <! 

fc     ->1 

(2;     ->i 

^-^ 

^.       < 

s^    o 

!«      < 

<^  -n 

a 

V- ^ 

■^-^ 

, 

^^-v^*-/ 

^.^■-v^W 

o 

TS 

ri 

o 

CO 

2 

"3 

2 

a 

c 

3 

d 

M 

3 

o 

a 

*c 

-^ 

o 

ro 

a 

35 

b 

b 

Eh 

* 

Eh 

•snoisioAOinv 

•SnOIBJOAOJJOJJ 

CHANGES    IN    THE    MENSTRUAL    FLOW    WITH    VEKSIONS.       305 

same  general  average  will  be  observed.  We  may  note  in  practice  great 
changes  in  the  amount  of  flow,  but  after  the  habit  as  to  time  has  been 
once  formed,  the  average  length  will  vary  but  little,  unless  the  circu- 
lation should  have  been  aftected  by  a  ncAV  growth. 

Two  divisions  have  been  made  in  the  table,  and  these  are  again 
subdivided.  The  first  is  composed  of  those  with  whom  the  length  of 
period  remained  unchanged  in  after  life.  In  the  second  are  those  with 
whom  both  length  and  quantity  became  changed.  The  first  division  is 
made  up  of  two  classes :  in  the  one,  menstruation,  whether  normal,  too 
free,  or  scanty,  remained  unchanged  both  in  length  and  quantity,  while 
in  the  other,  length  only  remained  unchanged,  but  the  quantity  became 
increased,  lessened,  or  irregular.  The  length  of  the  flow  of  those 
forming  the  first  class  of  the  second  division  became  increased,  while 
the  quantity  was  increased,  lessened,  or  became  irregular.  In  the  sec- 
ond class  the  length  of  flow  became  lessened,  while  the  quantity 
lessened,  increased,  or  became  irregular. 

In  connection  with  what  has  been  already  stated,  regarding  the 
changes  in  the  length  of  the  menstrual  flow,  it  will  be  of  interest  to 
note  that  those  forming  63.18  per  cent,  of  the  cases  of  ante  version 
and  58.44  per  cent,  of  the  retroversions  remained  unchanged.  Of  the 
first  subdivision  29.54  per  cent,  of  the  anteversions,  and  41.15  per  cent. 
of  the  retroversions  underwent  in  after  life  no  change  in  either  lenorth 
of  flow  or  in  quantity.  There  are  many  points  of  interest,  if  not  of 
practical  importance,  given  in  this  table,  particularly  in  the  compara- 
tive percentages  between  the  unmarried,  sterile,  and  fruitful  women. 

Table  XXIII.  is  a  summary  of  the  preceding  one,  giving  the  changes 
of  menstruation  for  both  forms  of  version,  without  reference  to  the 
social  condition.  That  menstruation,  as  is  shown  by  this  table,  should 
remain  normal,  without  change  in  either  length  or  quantity  of  flow,  in 
so  large  a  proportion  of  cases  sufiering  from  retroversion,  is  a  circum- 
stance for  which  no  explanation  can  be  ofiered.  It  is  even  more  sur- 
prising that  the  proportion  of  normally  menstruating  women  with  this 
form  of  displacement  should  be  much  greater  than  is  found  for  those 
with  anteversion. 

If  these  data  teach  us  anything,  it  is  that  these  displacements  are 
not  common  or  frequent  at  the  time  of  puberty,  and  that,  if  they  are, 
the  mere  position  of  the  uterus  is  of  little  moment  when  no  complica- 
tion exists. 

An  extreme  degree  of  anteversion  can  and  does  frequently  exist  as 
a  natural  position  for  some  uteri,  without  producing  the  slightest  incon- 
venience, unless  the  organ  becomes  enlai'ged,  from  some  obstruction 
20 


306      ETIOLOGY    AND    TREATMENT    OF    UTERINE    VERSIONS. 


!-•' 

joj  ■}U90  aaj 

IS. IS 
5.90 
37.27 
30.00 
8.63 

r-i  CO  O  I^  CO 

CO  o  as  CO  o 
CO  t-,  cr:  t-  t^ 

s 

CO 

•jiog  JO 
q:}Su9t  92B.19AV 

N  O  O  CO  ^ 
o  «  «>  ■*  '^ 

o 
o 

CC  CO  ^  O  C-l 
'J'  O  O  C  r-l 

Ti<  <ri  o  •*'  o 

o 

■sasMjo-o^     ^'"S'SS 

s 

n 

-C  -o  r^  CO  o 
to  i-i  :o  CO.-1 

CJ 

>4 

-«! 

o 

E-1 

•uoilipuoD  qoTia 
joj  -((uao  ja<i 

to  -t<  00 

-o  c-l  c^ 

CO  05  to 
COLO 

■Aiop:  JO 
Tl}§TI9X  ag'Bi'aAY 

O  7^  o 

■M 

O  CO  o 
CO  -f  CO 

to  CO  to 

-* 

•ses'BD  JO  -Oil 

«m 

s 

CO  t^  »o 

Oi  CO 

p 

<! 
& 
C? 
a 

■X, 

< 

o 
^, 

>A 

B 

o 
n 

3 

-^ 

G 

Length  of  flow 

lessened,  with  tho 

quantity  either 

•T-Biox 

?5 

-f 

•I'BxnSs.iJi 

.      .CO 

CO 
CO 

_ 

'pas'Baaoni 

■-  :  : 

lo 

'panassei 

CO      • 

■ 

o 
o 

o 

•  -* 

•CO 

Length  of  flow 

increased,  with  tho 

quantity  either 

•I^^oj, 

CO 

u'BinSaj.ii 

"if 

. 

^ 

.    .  o 

«■ 

'pauassai 

CO      • 

CO 
CO 

■CO     ■           ; 

CO 

'pas'BaJonj 

co' 

?5  :  : 

1:~ 

d 

5 

Eh 
O 

E-i 

•uoijtpnoa  qo'Ba     t^? 

joj  -^tnao  aaa    «  c- 
^1 

o  1^  m 

CO  lO  o 
— '  r-'  CO 

»- 

S 

CO^I  -f  CO 
O  CO  r-i  go 

Ci  t^  to  to 

•Aiog  JO 
qjSaajaSBJaAy 

(M  C 

CO  <Xi  03 

CO 

CC 

CO  o  to  to 

cr.  t~  C5  M 

CO 

•SaSBD  JO  •<3^ 

Tf  r^  -1>  «  ■-' 

CO 

to  rH  -*  !M  r-l 

-o 

0 

a 
c 

< 

o 

o 

<! 
&  . 

85 

C 

Longth  of  flow  re- 
mained unchanged, 
but  the  quantity  be- 

canio  afterwards, 
either 

•IiJ^ox 

:  :    ^ 

CO 

to 

■j'BxnSaaJi 

•  e-i 

:  :^ 

CO 

'panassai 

CO      • 

— 

CO 

to 

CO 

•  to     • 

.(M      . 

o 

'pas'EaJOTti 

CO      •      • 

CO      ■      • 

t^ 

Flow  remained  un- 
changed, as  to  length 
and  quantity,  beiug 
from  the  boginuiug 
either 

•I-Bjoj, 

o 

o 

CO 

-.^lU'EOS 

~5      .     .      . 

o 

to    •    .    . 

o 

*aajj  oox 

.  CI    .    • 

1.-5 

■o 

.  CO     •     ; 

'X'Bnuo^i 

O      •      •      •      • 

CO 

H4      .      .      .      . 

1^ 

.^3 

•  % 

.   .  ® 

•    •  u 

'.    '.  ® 

S  o  a 

u 

t-4 

"3 

"3 

d 
o 

1- 

1  tS 

:  o 
:  J 

■  o 

:  -■= 

.  1*  c 

f§! 

to 
u 

J: 

o 

CI 

o 

si 

ci  •- 

5  g 

1' 

1 

•snO(Sa9A9}UB  iOi 

snoiBjaAomaa  joj 

TREATMENT    OF    VERSIONS.  307 

to  its  circulation,  and  begins  to  prolapse.  These  tables  show,  as  we 
have  seen,  that  a  large  proportion  of  retroversions  can  exist  without 
any  change  necessarily  taking  place  in  menstruation.  Yet,  complete 
displacement  cannot  long  exist  without  producing  some  disturbance  of 
the  nervous  system.  From  continued  pressure  of  the  cervix  against 
the  anterior  wall  of  the  vagina,  reflex  irritation  is  likely  to  be  excited 
long  before  any  diseased  condition  becomes  established  in  the  organ 
itself.  This  is  the  condition  when  the  displacement  has  become  com- 
plete, but  the  uterus  does  sometimes  remain  for  years  partially  retro- 
verted,  without  producing  any  disturbance.  When  the  organ  is  re- 
troverted,  the  woman  is  certainly  more  liable  to  disease  than  she  would 
be  were  the  uterus  in  a  better  position.  But  it  is  not  until  the  circu- 
lation becomes  disturbed  by  some  accidental  cause,  and  prolapse 
takes  place,  that  the  demand  for  relief  becomes  urgent.  It  is,  there- 
fore, not  so  much  the  version,  as  the  prolapse  which  excites  disturb- 
ance in  the  circulation.  The  effect  of  prolapse  on  the  circulation  has 
been  shown  on  page  128,  and  that  the  same  result  follows  any  undue 
elevation  of  the  organ  in  the  pelvis  was  also  shown.  The  fact  that  a 
certain  number  of  cases,  suffering  from  retroversion,  should  have  the 
menstrual  flow  increased,  while  the  effect  with  others  should  be  to 
lessen  it,  may  possibly  excite  some  surprise.  The  condition  of  the 
flow  as  to  quantity  is  determined  almost  entirely  by  the  position  of 
the  uterus,  and  by  the  length  of  time  during  which  the  version  has 
existed.  When  the  displacement  has  not  been  extreme,  and  its  origin 
is  more  recent,  the  flow  is  generally  free.  On  the  other  hand,  when 
the  version  has  been  of  long  standing,  or  the  circulation  has  become 
very  much  obstructed,  from  the  existing  degree  of  displacement,  the 
period  becomes,  almost  without  exception,  scanty  or  irregular. 

Treatment  of  Versions. — A  version,  as  has  been  stated,  may  exist 
for  an  indefinite  period  without  causing  any  disturbance,  so  long  as 
the  organ  does  not  prolapse  sufficiently  to  increase  the  existing  ob- 
struction to  the  circulation.  Whenever  prolapse  has  occurred  to  an 
extent  calling  for  relief,  two  plans  of  treatment  will  be  applicable. 
First,  to  correct  the  displacement  and  version,  so  far  as  can  be  done 
by  mechanical  means.  Secondly,  to  relieve  the  local  cause  of  disease. 
Under  the  proper  head  extraneous  causes  of  version  will  be  treated 
of,  and  we  will  now  refer  only  to  the  management  of  what  we  have 
termed,  in  contradistinction,  idiopathic  version. 

The  local  treatment  should  consist  in  the  frequent  and  continued  use 
of  ho1>water  vaginal  injections,  and  of  appropriate  applications  to  the 
uterine  canal.    To  give  tone  to  the  bloodvessels  is  essential,  and  even 


308       ETIOLOGY    AND    TREATMENT    OP    UTERINE    VERSIONS. 

if  the  loss  of  power  were  confined  to  the  uterus  itself  (which  would 
be  rare)  we  possess  no  better  way  of  accomplishing  the  purpose 
than  through  the  action  of  the  hot  water  on  the  pelvic  vessels.  The 
details  of  local  and  general  treatment  have  already  been  so  fully 
considered  under  the  head  of  general  principles,  that,  to  avoid  repeti- 
tion, their  application  to  individual  forms  of  disease  must  be  left  to 
the  judgment  of  the  reader. 

When  mechanical  means  are  applicable  in  the  treatment  of  versions, 
we  Avill  accomplish  more  marked  results  in  the  prompt  relief  obtained, 
and  do  more  towards  the  final  restoration  to  health  than  by  any  other 
plan  of  procedure.  Retroversion  and  prolapse  are  the  only  forms  of 
displacement  for  the  correction  of  w^hich  we  possess  any  reliable,  or, 
as  a  rule,  safe  mechanical  means. 

When  the  uterus  falls  forward,  or  to  either  side,  we  can  only  relieve 
the  sagging,  or  prolapse  of  the  organ  in  the  pelvis,  by  mechanical 
means.  I  have  for  many  years  held  the  view  that  an  anteversion  of 
the  uterus  is  not  a  mal-position.  That  no  degree  of  version  will  cause 
irritation  of  the  bladder  so  long  as  the  uterus  remains  in  a  healthy 
condition.  But  whenever  the  uterus  becomes  heavy  from  any  cause, 
it  will  settle  down  in  the  pelvis,  and  the  irritation  produced  will  be  in 
proportion  to  the  amount  of  traction  exerted  along  the  anterior  wall 
of  the  vagina.  Vesical  disturbance  will  occur  as  soon  as  the  uterus 
reaches  a  point  in  the  pelvis  where  traction  is  exerted  directly  on  the 
neck  of  the  bladder,  and  this  occurs  when  either  prolapse  takes  place 
or  the  uterus  is  dragged  upAvard.  I  have  verified,  beyond  question, 
the  correctness  of  my  view,  that  no  degree  of  anteversion  without 
prolapse  produces  disturbance,  and  that  no  relief  is  ever  obtained  by 
simply  lifting  the  uterus  to  an  upright  position  unless  the  prolapse 
is  also  corrected. 

I  have  several  times  opened  the  bladder  by  making  a  vesico-vaginal 
fistula,  for  the  relief  of  chronic  cystitis  in  cases  Avhere  the  uterus  was 
enlarged  and  anteverted.  For  a  long  time  I  was  puzzled  to  account 
for  the  irritation  and  frequent  desire  to  empty  the  bladder,  which 
Avould  continue  after  the  operation,  although  I  had  satisfied  myself  that 
every  drop  of  urine  escaped  through  the  artificial  opening  immedi- 
ately after  entering  the  bladder.  I  had  also  noticed  the  same  irrita- 
tion continue  after  the  operation,  when  the  uterus  was  retroverted. 
In  both  instances  the  original  cause  of  the  cystitis  was  the  displacement 
of  the  uterus.  With  the  anteversion,  the  uterus  was  prolapsed,  and 
dragged  the  vesico-vaginal  septum  downAvard  until  traction  was  made 
directly  on  the  neck  of  the  bladder.     With  the  retroversion,  the  same 


TREATMENT    OF    VERSIONS.  309 

effect  was  produced  by  the  dragging  of  the  neck  of  the  lAadder  upward. 
The  irritation  of  the  bladder  was  not  relieved  until  the  prolapse  was  cor- 
rected by  lifting  the  uterus,  without  regard  to  the  version,  and  main- 
taining it  in  its  proper  place  by  an  instrument.  In  the  other  instance 
the  retroversion  had  to  be  corrected,  and  the  traction  upward  on  the 
neck  of  the  bladder  removed  by  a  properly  fitting  pessary. 

Various  devices  have  been  contrived,  with  the  exercise  of  much 
ingenuity,  for  forcing  the  organ  into  an  upright  position,  and  to  a 
point  which,  in  all  probability,  it  never  occupied.  Any  instrument 
making  direct  pressure  on  the  anterior  wall  of  the  uterus,  which  is  the 
chief  seat  of  disease,  and  usually  very  tender,  must  prove  a  source 
of  irritation.  Such  a  plan  of  treatment  is  faulty  in  theory,  and 
pernicious  in  practice.  When  these  instruments  give  any  relief, 
the  result  is  brought  about  simply  by  their  lessening  the  degree  of 
prolapse.  Even  in  the  hands  of  an  expert,  great  harm  sometimes 
results  from  their  use,  and  as  all  benefit  to  be  derived  can  be  obtained 
by  simpler  and  safer  means,  these  instruments  should  cease  to  be  so 
generally  employed.  If,  by  any  appliance,  we  can  lift  the  uterus  to 
a  point  where  the  obstructed  venous  circulation  through  the  neighbor- 
ing tissues  can  be  relieved,  it  is  all  that  can  be  accomplished  by  such 
means. 

Great  relief  may  be  obtained  by  even  increasing  the  degree  of 
anteversion  through  the  use  of  a  pessary  with  a  long  enough  curve 
in  the  posterior  cul-de-sac,  so  as  to  lift  the  neck  of  the  organ  from 
the  floor  of  the  pelvis.  By  thus  slinging,  as  it  were,  the  uterus  with 
the  fundus  resting  against  the  pubis,  and  the  cervix  elevated,  the 
circulation  will  rapidly  improve,  and  the  irritability  of  the  bladder  be 
lessened.  We  will  also  gain  time  by  this  means,  since  it  will  enable 
the  patient  to  take  more  out-door  exercise  ;  and,  by  the  use  of  the 
pessary,  we  will  break  the  force  or  jar  which  is  transmitted  with  every 
step  to  the  uterus,  so  long  as  the  cervix  rests  on  the  floor  of  the  pelvis. 

The  treatment  of  retroversion  of  the  uterus  is  more  satisfactory, 
mechanical  means  can  be  better  applied,  and  the  good  resulting  from 
relieving  the  obstructed  circulation  is  well  marked  on  restoring  the 
organ  to  its  natural  position.  A  recent  case  of  retroversion  can  be 
reduced  with  comparative  ease,  and  an  instrument  may  be  readily 
adjusted,  which  will  keep  the  organ  so  far  anteverted  that  it  cannot 
return  to  its  former  position.  If,  however,  the  displacement  has  been 
of  long  duration,  and  the  uterus  has  become  flexed,  the  condition  will, 
in  all  probability,  have  acted  as  a  source  of  irritation  in  causing  cellu- 
litis more  or  less  extensive.     Frequently,  even  when  no  adhesion  has 


310      ETIOLOGY    AXD    TREATMENT    OF    TJTERINE    VERSIONS. 

been  formed,  a  degree  of  congestion  may  have  been  kept  up,  which 
would  require  but  a  slight  provocation  to  establish  a  fresh  attack  of 
inflammation.  It  is,  therefore,  wise  to  proceed  with  the  greatest 
caution  in  any  attempt  for  reducing  a  retroverted  uterus,  until  we 
have  been  able  fully  to  appreciate  the  condition.  Should  we  find  the 
uterus  firmly  bound  down  by  adhesions,  an  unfavorable  prognosis 
should  not  necessarily  be  given,  for  the  organ  may  be  replaced  in 
time  by  exercising  care,  patience  and  good  judgment.  The  reduction 
should  not  be  attempted  in  a  single  effort  but  by  frequent  efforts,  so 
that  these  bands  may  at  length  become  so  stretched  and  attenuated 
as  to  offer  no  longer  any  resistance. 

The  utero-sacral  ligaments,  when  not  in  a  diseased  condition,  are 
scarcely  worthy  of  note,  since  they  consist  only  of  a  reduplication  of 
the  peritoneum,  and  a  little  cellular  tissue.  These  ligaments,  how- 
ever, frequently  become  thickened  from  inflammation.  Whenever  the 
retroversion  becomes  complete,  so  that  these  thickened  ligaments 
partially  close  over  the  enlarged  uterus,  they  often  present  an  ob- 
stacle, when  we  attempt  to  replace  the  organ,  which  might  easily  be 
mistaken  for  adhesions. 

A  retroverted  uterus  may  be  restored  to  its  natural  position  by  the 
sound,  the  elevator,  or  the  finger,  or  by  means  of  position  and  atmo- 
spheric pressure. 

If  we  can  ascertain  the  fact  or  feel  reasonably  satisfied  that  neither 
adhesions  nor  lurking  inflammation  exists  in  the  neighboring  cellular 
tissue,  we  may,  with  comparative  safety,  lift  the  uterus  with  the  sound 
or  any  other  means  to  which  we  have  been  accustomed.  The  use  of 
the  sound,  however,  for  this  purpose,  almost  always  produces  pain,  and 
can  never  be  regarded,  even  in  the  most  skilful  hands,  as  a  means  free 
from  risk.  The  use  of  the  elevator  has  already  been  fully  described, 
and  with  ordinary  care  or  dexterity,  the  instrument  may  be  deemed 
safe,  and  should  cause  but  little  or  no  pain.  The  effect  and  employ- 
ment of  atmospheric  pressure  has  also  been  fully  considered. 

I  have  long  accustomed  myself  to  rely  on  the  use  of  the  index 
finger  for  lifting  a  retroverted  uterus  into  place,  and,  with  a  little 
practice,  it  becomes  the  most  reliable  means  we  can  employ.  It  is 
one  certainly  attended  Avith  the  least  risk,  as  we  are  able  to  appreciate 
at  once,  in  case  of  adhesions,  the  point  and  extent  of  resistance. 
For  employing  this  method  the  patient  is  to  be  placed  on  the  back, 
with  the  knees  flexed,  and  the  hips  drawn  down  to  the  edge  of  the 
operating  table  or  chair.  Introduce  then  the  index  finger  into  the 
vagina,  and  direct  the  point  of  the  tenaculum  so  that  it  may  be  hooked 


TREATMENT    OF    RETROVERSION. 


311 


into  the  posterior  lip  just  within  the  os.  This  instrument  is  to  be 
used  for  the  purpose  of  gently  drawing  forward  the  organ  sufficiently 
toward  the  vaginal  outlet,  that  Ave  may  be  satisfied  the  fundus  is  dis- 
tant enough  from  the  hollow  of  the  sacrum  to  pass  the  promontory 
when  elevated.  At  the  first  attempt  this  manipulation  must  be  done 
with  care,  and,  if  a  point  is  reached  at  which  great  pain  is  produced, 
we  must  desist.  By  this  manoeuvre  the  uterus,  of  course,  becomes 
more  retroverted  than  before.  To  correct  this,  the  perineum  should 
be  pressed  firmly  back,  that  the  finger  in  the  vagina  may  be  passed 
up  as  far  behind  the  uterus  as  possible,  and  made,  at  the  same  time, 
to  lift  the  organ.  When  the  fundus  of  the  uterus  has  been  thus  ele- 
vated, and  while  it  is  being  held  up  by  the  finger,  the  cervix  is  to  be 
suddenly  carried  in  an  arc  of  a  circle,  downward  and  backward  by 
means  of  the  tenaculum  which  has  been  hooked  in  the  anterior  lip, 


Fis.  52. 


Mode  of  correcting  a  retroversion. 

and  is  held  in  the  other  hand.  When  the  version  has  become  com- 
plete, the  fundus  can  be  pressed  up  against  the  utero-sacral  ligaments 
by  aid  of  the  finger  in  the  vagina.  These  ligaments,  having  thus  been 
put  slightly  on  the  stretch,  gape  as  the  tension  is  suddenly  relaxed 
by  carrying  the  cervix  backward,  and  the  fundus  then  slips  between 
them.     The  finger  must  be  quickly  passed  from  the  posterior  cul-de- 


312      ETIOLOGY    AND    TREATMENT    OF    UTERINE    VERSIONS. 

sSbC  against  the  anterior  lip,  the  tenaculum  withdrawn,  and  the  organ 
thrown  forward  bypassing,  as  shown  in  Fig.  52,  the  finger  repeatedly 
down  the  anterior  face  of  the  uterus,  so  as  to  press  the  cervix  down- 
ward and  backward  into  the  hollow  of  the  sacrum. 

A  glance  at  the  figure  Avill  show  that  the  anterior  wall  of  the 
bladder  A — B,  when  made  tense,  becomes  the  fulcrum  at  A,  over 
which  the  leverage  is  exerted.  Therefore,  when  the  cervix  is  pressed 
downward  and  backward,  the  fundus  must  to  the  same  extent  go  for- 
ward in  the  direction  indicated  by  the  arrow.  This  manoeuvre,  how- 
ever, will  be  found  at  first  more  rational  in  theory  than  easy  in  prac- 
tice, since  it  requires  some  dexterity  or  sleight  of  hand  to  accomplish  it. 

The  uterus  is  represented  in  the  figure  as  if  it  had  been  drawn  for- 
ward, and  the  fundus  released  from  under  the  promontory  of  the 
sacrum.  If  the  organ  were  left  in  this  position,  the  cervix  would  soon 
settle  towards  the  vaginal  outlet,  and  the  fundus  into  the  hollow  of  the 
sacrum.  It  is,  therefore,  necessary  to  antevert  the  uterus  immediately, 
and  fit  an  instrument  which  will  lift  it  in  the  pelvis,  and  at  the  same 
time  carry  the  cervix  so  far  backward  that  the  weight  of  the  organ  itself 
will  keep  the  fundus  forward.  If  there  were  nothing  in  the  pelvis  in 
front  of  the  uterus  but  the  bladder,  as  represented  in  the  figure,  it 
would  be  easy  to  eifect  this.  The  intestines,  however,  are  packed 
about  the  upper  part  of  the  uterus,  and  have  to  be  displaced  before 
the  organ  can  be  made  to  occupy  another  position.  If  we  were  sim- 
ply to  press  the  cervix  downward  and  backward  by  a  single  eifort, 
the  rectum  behind,  and  the  intestines  above,  would  be  temporarily 
compressed  by  the  fundus,  but  they  would  immediately  recover  their 
elasticity  when  the  force  was  removed,  and  reproduce  the  origi- 
nal condition.  The  sleight  of  hand  consists  in  keeping  up  the  steady 
movement  of  the  cervix  backward,  effecting  the  manipulation  by  a 
number  of  efforts,  instead  of  a  single  one,  the  uterus  being  allowed 
to  spring  back,  or  slightly  recover  itself,  after  each  advance.  Then 
the  cervix  having  been,  by  this  means,  carried  as  far  back  towards 
the  hollow  of  the  sacrum  as  the  length  of  the  finger  will  permit,  the 
manoeuvre  must  be  repeated  again  and  again  until  at  length  the 
fundus  Avill  have  become  turned  over  on  to  the  bladder. 

If  an  unusual  degree  of  pain  is  experienced  at  any  point,  we  must 
use  our  judgment  as  to  how  far  it  may  be  safe  to  proceed,  or  desist 
entirely  for  the  time  being,  until  all  acute  symptoms  shall  have  subsided 
under  the  proper  treatment.  Even  when  successful,  I  frequently  make 
no  attempt,  by  mechanical  means,  to  hold  the  uterus  in  position.  I 
wait  until  I  have  again  replaced  it,  and  have  satisfied  myself  that  no 


TREATMENT  OF  RETROVERSION.  313 

tenderness  on  pressure  exists  at  any  point  Avhich  would  come  in  contact 
Avith  the  pessary  to  be  used. 

It  is  -wise  to  proceed  with  great  care  after  the  reduction  of  a  re- 
troversion of  long  standing.  Whenever  I  have  met  with  more  difficulty 
than  usual,  or  have  caused  much  pain  in  treating  an  office  patient,  I 
always  have  a  large  hot-water  vaginal  injection  administered  immedi- 
ately, followed  by  a  glycerine  dressing  in  the  vagina,  and  order  sev- 
eral hours'  rest  before  allowing  the  patient  to  return  home.  When 
treating  patients  in  my  hospital,  under  the  same  circumstances,  I 
keep  them  in  bed  twenty-four  hours,  as  a  precaution.  The  result  is 
that  I  now  no  longer  have  a  dread  of  exciting  cellulitis,  which  was 
formerly  of  frequent  occurrence,  when  less  care  was  taken  to  guard 
asrainst  it. 


314  ■  PESSARIES. 


CHAPTER   XYI. 

PESSARIES. 

Proper  time  for  their  use — Peculiarities  to  be  met — Object  of   pessaries — Indi- 
ridual  form^s — Block-tin  for  modelling — Adjusting  pessaries. 

This  subject  is  one  of  the  most  important  and  the  least  understood. 

There  is  a  proper  time  for  using  these  instruments,  just  as  there  is 
for  a  splint :  and  there  is  also  a  proper  manner  of  applying  them. 

Without  full  appreciation  of  both  of  these  requirements,  the  damage 
inflicted  by  employing  pessaries  will  be  far  greater  than  any  chance 
benefit  which  may  be  obtained  from  them.  From  some  members  of 
the  profession,  the  opposition  to  the  use  of  pessaries  is  as  denunciatory 
as  if  they  were  condemning  a  species  of  malpractice.  This  opposition 
mar  be  sincere,  but  it  is  conclusive  evidence  of  their  ignorance.  I 
have  never  known  a  practitioner  who  was  able  to  fit  a  pessary 
properly,  who  was  not  also  fully  satisfied  with  the  amount  of  benefit 
derived  from  its  use. 

The  practitioner,  to  become  an  expert  in  fitting  a  pessary  that  it 
may  do  no  harm,  must  have  a  decided  mechanical  talent;  and,  that 
the  full  benefit  may  be  derived  from  the  use  of  the  instrument,  he 
must  be  able  to  appreciate  slight  shades  of  difference  which  would  be 
entirely  overlooked  by  others.  The  first  is  a  gift,  which  cannot  be 
acquired;  the  second  can  be  gained  by  experience,  but  is  of  little 
practical  value  unless  associated  with  the  first.  I  have  known  physi- 
cians, who,  although  quite  dexterous  in  moulding  the  instrument,  that 
it  should  do  no  harm,  habitually  failed  in  obtaining  benefit  from  it, 
through  want  of  observation  or  appreciation  of  what  was  to  be  accom- 
plished in  the  individual  case.  Frequently,  physicians  have  written 
to  me  with  the  request  that  I  would  send  them  a  pessarj^  for  some 
case  then  under  treatment,  without  their  appreciating  the  necessity 
for  doing  as  much  as  they  would  consider  essential  in  order  to  obtain 
satisfaction  in  the  fitting  of  a  hat  or  any  garment  procured  through 
the  aid  of  another  person.  The  great  cause  of  failure  and  disappoint- 
ment in  the  use  of  pessaries  lies  in  the  fact  that  the  vagina  is 
expected  by  many  to  adapt  itself  to  any  instrument  which  may  be 
introduced,  when  in  fact  it  is  essential  that  the  peculiarities  of  each 


OBJECT    OF    PESSARIES.  315 

individual  case  should  be  studied.  In  adjusting  a  pessary,  the  phy- 
sician should  pay  as  much  regard  to  the  peculiarities  of  shape  and 
size  of  the  vagina  as  the  dentist  does  to  those  of  the  mouth  when 
fitting  a  set  of  false  teeth.  I  am  fully  aware  that  it  will  be  con- 
sidered an  extravagant  statement  by  many,  but,  nevertheless,  I  do 
not  hesitate  to  make  the  assertion  that  scarcely  two  women  can  be 
found  who  will  be  benefited  by  wearing  exactly  the  same  shaped 
instrument.  Fortunately,  it  is  true,  there  are  many  women  wlio  are 
able  to  tolerate  an  ill-fitting  instrument  without  receiving  injury,  but 
they  are  not  benefited,  except  it  be  by  sheer  good  luck. 

Several  years  ago,  I  was  urged  to  endorse  a  pessary  which  had  some 
merit,  but  it  had  been  patented.  I  refused  on  this  ground,  and  as  a 
matter  of  principle,  since  my  self-respect  would  not  allow  my  name  to 
be  associated  with  anything  which  was  to  be  advertised.  The  inventor 
was  so  importunate  that,  to  get  rid  of  him,  I  pointed  to  a  lot  of  old  pes- 
saries and  told  him,  if  he  could  find  any  two  which  were  exactly  of 
the  same  size  and  shape,  I  would  change  my  mind.  I  had  just  had  my 
office  refitted,  and  into  a  small  keg  there  had  been  thrown  the  accumu- 
lations of  many  years,  in  the  shape  of  pessaries  which  had  been 
formed  from  the  ordinary  block-tin  rings.  In  full  confidence,  this 
man,  having  spread  them  over  the  floor,  spent  several  hours  looking 
over  between  five  and  six  hundred  pessaries  which  had  been  fitted 
and  worn  by  as  many  individuals,  but  was  unable  to  find  what  he 
sought  for. 

By  reference  to  Chapter  VIII.,  page  125,  it  will  be  seen  that  the 
necessity  has  been  insisted  upon  for  restoring  the  uterus  to  its  proper 
place  in  the  pelvis,  where  the  circulation  will  be  completely  estab- 
lished. Unless  this  be  done,  it  will  prove  a  matter  of  little  conse- 
quence how  much  care  may  have  been  bestowed  on  the  shape  of  a 
pessary.  The  common  error  committed  when  attempting  to  correct 
a  prolapse,  is  to  lift  the  uterus  too  high  in  the  pelvis  ;  just  in  propor- 
tion as  this  is  done  above  the  health  plane,  by  so  much  will  traction 
be  made  on  the  connective  tissue  of  the  pelvis  to  obstruct  the  circula- 
tion, and  with  the  same  effect  as  if  the  organ  had  prolapsed  to  that 
degree  below  the  proper  line.  It  has  been  shown  that  when  the  pro- 
lapsed uterus  is  gently  lifted  from  the  floor  of  the  pelvis  on  the 
extremity  of  the  finger,  a  point  will  be  reached  when  the  patient  will 
express  herself  as  being  relieved  of  all  feeling  of  fulness  and  bearing- 
down.  This  feeling  is  to  be  our  guide,  and  a  valuable  one  it  is  when 
the  patient  is  able  to  appreciate  it.  It  is  impossible  to  teach  any  one 
this  art  of  judging  of  just  how  high  the  uterus  should  be  lifted;  it 


316  PESSARIES. 

can  be  gained  by  experience  alone,  and  then  only  by  those  who  have 
been  gifted  by  nature  with  the  faculty  of  observation,  AYhen  our 
judgment  happens  to  be  confirmed  by  the  feelings  of  the  patient,  the 
result  cannot  be  otherwise  than  satisfactory.  It  must  be  accepted 
as  a  rule,  that  when  the  instrument  fits  properly,  and  has  corrected 
the  prolapse,  the  patient  will  be  unconscious  of  its  presence  in  the 
vagina,  and  shall  only  realize  the  fact  from  the  sense  of  relief  afforded 
while  standing  or  walking.  It  is  scarcely  probable  that  those  who 
object  to  pessaries  will  be  likely  to  attribute  their  past  failures  in 
obtaining  good  results  from  the  use  of  the  instrument  to  some  defect 
within  themselves.  Yet,  they  may  rest  assured  that  such  has  been 
the  case  invariably,  if  the  failures  have  occurred  when  the  patient 
Avas  in  a  proper  condition  to  wear  an  instrument. 

The  Form  of  Pessaries  to  he  Used. — Far  more  is  dependent  on 
the  operator  than  on  the  actual  form  of  the  pessary.  One  skilled 
could  eifect  more  by  a  simple  piece  of  bent  wire,  or  by  a  pad  of  cotton, 
properly  placed  in  the  vagina,  than  another  could  with  the  aid  of  a 
complete  armamentarium.  Some  modification,  however,  of  Hodge's 
closed  lever  pessary,  will  be  found  applicable  to  the  largest  number 
of  cases,  as  it  conforms  more  nearly  than  any  other  to  the  natural 
shape  of  the  vagina.  The  pessary  should  be  fitted  for  the  vagina 
without  any  outside  appliance  whatever,  and  to  accomplish  this  is  the 
perfection  of  the  art.  In  practice  we  will  scarcely  ever  meet  with  a 
case  in  which  this  cannot  be  effected,  but  it  often  requires  exceptional 
skill.  If  there  were  no  other  objection  to  every  outside  appliance, 
the  fact  that  the  patient  has  to  be  manipulating  it  constantly  would 
be  suflBcient  to  condemn  it,  and  there  can  be  no  better  plan  devised 
for  rendering  a  woman  a  confirmed  invalid.  After  fitting  a  pessary, 
all  aid  should  be  given  her  to  forget,  as  long  as  possible,  that  she  is 
wearing  a  support,  and  this  cannot  be  done  if  any  portion  be  outside. 
Once  the  instrument  has  been  given  the  proper  shape,  it  does  not 
require  to  be  removed  for  months,  during  which  time  the  uterus 
is  supported  steadily,  without  change,  at  the  same  plane  in  the  pelvis, 
thus  facilitating  the  gradual  recovery  of  tone  in  the  uterine  liga- 
ments. But,  so  long  as  the  instrument  has  to  be  removed  several 
times  a  day,  and  the  position  of  the  uterus  is  as  often  changed,  no 
permanent  advance  will  be  made  towards  recovery. 

After  the  conception  of  Hodge's  closed  lever  pessary,  I  consider 
the  most  important  advance  was  made  by  Dr.  Sims,  about  1859,  in 
his  recognition  of  the  importance  of  fitting  each  pessary  to  the 
vagina,  and  in  his  suggesting  the  block-tin  rings.     These  rings  are 


ADJUSTING    PESSARIES. 


BIT 


made  of  an  alloy  of  tin  and  lead,  in  such  proportions  as  to  be  easily 
moulded,  and  yet  unyielding  enough  for  the  pessary  to  keep  its  shape 
when  placed  in  the  vagina.  After  using  these  for  some  eighteen 
years,  upon  every  occasion  of  their  use  endeavoring  to  make  each 
instrument  individual  in  its  conformation,  I  believe  that  it  would  he 
impossible  to  devise  a  form  of  pessary  that  I  have  not  employed. 

Previous  to  1868,  I  took,  as  a  rule,  the  support  for  the  instrument 
behind  the  symphysis,  but  since  that  time  I  have  preferred  to  take  it 
from  the  bottom  of  the  posterior  cul-de-sac.  The  shape,  as  given  in 
Fig.  53,  or  some  modification  of  it,  represents  the  pessary  I  have 

FiV.  53. 


Block-tiu  pessary. 


generally  employed  at  the  Woman's  Hospital,  and  also  in  private  prac- 
tice, since  the  date  mentioned.  It  is  of  block-tin,  moulded  into  proper 
shape,  which  may  thus  be  used,  or  it  may  serve  as  a  model  for  one 
to  be  made  of  hard-rubber,  aluminium,  or  silver  (gilded).  Some 
time  since,  I  furnished  Dr.  Leonard,  of  the  firm  of  Shepard  and 
Dudley,  of  New  York,  six  pessaries  of  different  sizes,  but  of  the 
same  general  shape,  to  be  made  into  hard- rubber.  He  has  succeeded 
so  well,  that  I  now  depend  entirely  on  those  furnished  by  him,  only 
making  such  slight  alterations  as  may  be  needed  for  any  individual 
case.  This  is  very  readily  done  by  means  of  a  gas  jet  or  a  spirit  lamp, 
care  being  taken,  before  heating  the  rubber,  to  smear  the  surface  well 
with  some  simple  ointment  fi-ee  from  water.  The  grease  is  necessary 
to  prevent  the  rubber  from  taking  fire,  and  it  should  be  free  from 
water,  as  the  steam  causes  the  rubber  to  break  while  being  bent. 
The  surface  to  be  moulded  must  be  heated  gradually,  and  if  any  por- 
tion should  take  fire,  it  must  be  withdrawn  for  a  second  and  more 
grease  applied.  Whenever  the  substance  has  become  soft  enough,  it 
is  easily  moulded  into  the  desired  shape,  and  can  be  held  in  this  form 


318  PESSARIES. 

by  the  fingers  until  dipped  into  cold  water  to  harden  it.  These  pessa- 
ries, made  by  the  models  I  have  furnished,  conform  so  closely  to  the 
general  shape  of  the  vagina,  that  after  a  selection  of  the  proper 
length,  they  seldom  require  to  be  altered,  except  as  to  the  width  at 
any  point,  the  curve  for  the  posterior  cul-de-sac,  or  the  arc  for  the 
neck  of  the  bladder. 

An  instrument  on  the  principle  of  the  closed  lever  pessary,  and  of 
the  same  general  shape  as  those  furnished  Dr.  Leonard,  will,  accord- 
ing to  my  experience,  furnish  the  most  useful  form  of  support. 
But,  to  receive  the  full  benefit  from  its  use,  it  is  necessary  that  the 
vaginal  outlet  should  not  be  too  large,  and  that  the  posterior  cul- 
de-sac  be  of  a  natural  depth.  The  fulcrum  of  this  double  lever 
rests  on  the  bottom  of  the  cul-de-sac,  and  in  front  against  the  poste- 
rior wall  of  the  vagina.  This  latter  support  will  prevent  the  instru- 
ment from  slipping  forward  if  there  is  no  prolapse  of  the  vaginal 
column  below  from  absence  of  the  perineum.  The  instrument  should 
be  curved  at  one  extremity,  with  reference  to  the  shape  of  this 
cul-de-sac  and  posterior  wall,  and  bent  at  the  other  end  in  the  op- 
posite direction  with  a  lesser  curve,  so  that  it  will  be  balanced,  as  it 
were,  in  the  vagina.  But  when  the  patient  stands  on  her  feet,  the 
weight  of  the  uterus  will  be  thrown  on  the  short  lever  forming  the 
long  curve  in  the  posterior  cul-de-sac.  The  leverage  thus  exerted 
will  cause  the  other  end,  or  long  lever,  to  be  elevated,  so  as  to  rest 
against  the  anterior  wall  of  the  vagina,  near  the  neck  of  the  blad- 
der. This  action  is  identically  the  same  as  if  a  weight  were  applied 
to  the  tail-board  of  a  cart  heavy  enough  to  elevate  the  shafts. 
As  the  woman  assumes  the  horrizontal  position,  and  the  Aveight  of 
the  uterus  is  again  removed,  the  long  lever  of  the  instrument  will  rest 
in  the  axis  of  the  vagina.  This  rocking  movement  does  not,  however, 
change  the  position  of  the  uterus  to  any  appreciable  degree.  As  the 
posterior  lever  becomes  depressed  from  the  weight  of  the  uterus  above, 
the  instrument  will  slide  forward,  in  consequence  of  the  shape  of  the 
cul-de-sac.  This  will  take  place  just  sufficiently  along  the  upward 
curve  of  the  posterior  wall  of  the  vagina,  to  compensate  and  prevent 
the  occurrence  of  any  prolapse.  Then,  as  the  weight  of  the  uterus 
is  removed,  and  the  long,  lever  of  the  instrument  lies  in  the  axis  of 
the  vagina,  the  posterior  curve  regains  its  position  at  the  bottom  of 
the  cul-de-sac.  The  instrument  will  thus  adjust  itself  by  a  change 
of  position,  so  that  it  cannot  cut  into  the  vaginal  tissues  from  continued 
pressure  at  any  one  point. 

Whenever  it  is  possible  to  avoid  making  the  pubis  the  chief  point 


ADJUSTING    PESSARIES.  319 

of  support,  it  should  be  done.  But  it  is  often  unavoidable  when  the 
anterior  wall  of  the  vagina  has  become  shortened  in  consequence  of 
retroversion  which  has  been  of  long  standing,  and  where  prolapse  of 
the  posterior  wall  has  been  produced  from  laceration  of  the  perineum. 
Whenever  the  vaginal  outlet  has  become  so  open  as  to  permit  the 
anterior  and  posterior  walls  of  the  vagina  to  prolapse,  a  surgical 
operation,  to  be  described  hereafter,  will  be  necessary.  Closure  of 
the  laceration  through  the  perineum  will  be  required  before  any 
properly  fitting  support  can  be  worn  with  advantage  for  correct- 
ing the  retroversion.  But  before  this  can  be  accomplished  some 
pessary  will  be  needed  as  a  temporary  means  of  relief,  and  the  only 
available  point  of  support  will  be  from  behind  the  symphysis.  An 
instrument  fitted  under  such  circumstances  must  be  made  wider  below, 
and  Avith  the  greater  curve  also  at  this  end,  so  that  any  downward 
pressure  may  have  the  efiect  of  crowding  the  anterior  extremity  of  the 
pessary  well  up  behind  the  pubes.  This  renders  it  always  necessary 
that  a  depression  be  made  in  the  instrument  to  protect' the  neck  of 
the  bladder,  since  the  chief  support  of  the  instrument  must  be  gained 
in  this  neighborhood. 

There  are  certain  general  laws  which  are  equally  applicable  to  the 
adjusting  of  all  forms  of  pessaries.  That  such  an  instrument  should 
do  no  harm,  it  is  necessary  that  it  be  small  enough  to  admit  of  the 
passage  of  the  finger  between  it  and  the  vaginal  wall  at  any  point 
while  the  patient  lies  on  the  back.  It  must  be  just  large  enough  to 
give  the  needed  support  to  the  uterus,  and  be,  at  the  same  time,  small 
enough  to  enable  the  vagina  to  regain  gradually  its  natural  size. 
The  elasticity  of  the  canal  is  sufficient  to  admit  of  a  dilatation  to  the 
extent  of  the  pelvic  excavation,  but  it  will  be  an  exception  to  the  rule 
when  a  pessary  properly  curved  need  ever  be  over  three  inches  in 
length  and  about  an  inch  and  a  half  in  width.  To  obtain  the  proper 
length  for  the  pessary,  my  rule  is,  while  the  patient  lies  on  the  back, 
to  pass  the  whalebone  stick,  or  any  blunt  instrument,  along  the  index 
finger  into  the  posterior  cul-de-sac,  and  measure  from  behind  the  pubes. 
I  place  the  index  finger  behind  the  symphysis  pubis,  and  then  withdraw 
both  it  and  the  stick  together,  and  take  the  ascertained  measurement, 
less  the  thickness  of  the  finger,  as  a  guide  for  the  length  of  the  instru- 
ment. Thus  measured,  the  instrument  will  be  found  of  just  the  proper 
length,  if  the  woman  be  examined  while  standing.  After  determining 
this  important  point,  the  next  step  will  be  to  give  the  proper  curve  to 
that  portion  of  the  instrument  Avhich  is  to  rest  in  the  posterior  cul-de- 
sac.     When  retroversion  has  existed,  a  longer  curve  will  be  needed 


320  PESSARIES. 

in  the  cul-de-sac  than  when  the  instrument  is  required  to  lift  the  organ 
from  the  floor  of  the  pelvis  to  relieve  a  prolapse,  after  enlargement  of 
the  uterus.  With  the  latter  condition,  the  upper  portion  of  the  vagina 
•will  be  somewhat  pear-shaped,  or  more  dilated  than  below,  and  it 
will  be  necessary  to  make  the  instrument  conform  to  this  peculiarity. 
When  a  pessary  is  thus  made  larger  above,  so  that  the  vaginal  walls 
can  close  about  it  below,  the  effect  is  to  crowd  it  upwards  into  the 
canal.  An  instrument  should  never  be  so  abruptly  curved,  in  the 
posterior  cul-de-sac,  as  to  make  direct  pressure  against  the  uterus  at 
its  junction  with  the  vagina,  but  at  some  little  distance  beyond  it. 
The  circulation  in  the  neck  and  lower  portion  of  the  body  is  easily 
obstructed  by  pressure  at  this  point.  The  consequence  is,  that  en- 
gorgement of  the  uterus  is  soon  produced,  and,  in  the  eifort  of  nature 
to  relieve  it,  a  discharge  takes  place,  which  will  form  an  erosion 
about  the  os,  to  be  mistaken,  in  all  probability,  for  and  treated  as 
ulceration.  Even  a  more  serious  consequence  arises  if  there  be  an 
urgent  necessity  for  wearing  a  pessary.  For,  from  direct  pressure  a 
state  of  irritation  or  inflammation  of  the  lymphatic  glands  found  in 
this  neighborhood  frequently  becomes  established,  with  an  intolerance 
to  the  presence  of  any  instriiment  in  the  posterior  cul-de  sac.  Should 
the  anterior  wall  of  the  vagina  be  short,  and  the  curve  of  the  pessary 
be  such  as  to  rest  just  at  the  junction  of  the  vagina  and  uterus,  the 
instrument  must  necessarily  form  a  fulcrum,  over  which  the  organ  will 
soon  become  retroverted.  For  those  cases  in  which  there  is  thickening 
of  the  posterior  wall  and  retroversion,  it  is  absolutely  necessary  that 
the  curve  of  the  instrument  be  such  that  it  will  pass  as  far  as  possible 
beyond  the  uterus  into  the  cul-de-sac.  This  is  necessary,  not  only 
that  it  should  not  furnish  the  fulcrum  to  reproduce  the  displacement, 
but  also  that  the  instrument  va?Lj  not  cause  irritation  by  touching  the 
posterior  wall  of  the  uterus,  which,  in  such  cases,  is  always  sensitive 
on  pressure.  As  a  rule,  we  cannot  change  a  retroversion  except  by 
lifting  the  organ  bodily  up  in  the  pelvis  with  a  pessary  so  curved  as 
to  go  far  beyond  into  the  cul-de-sac,  as  represented  in  Fig.  54.  The 
uterus  must  then,  in  time,  become  anteverted  and  the  flexure  will  be 
overcome.  When  the  uterus  is  thus  suspended,  as  shown  in  the 
figure,  from  the  curve  of  a  pessary,  which  extends  too  far  above  to 
admit  of  the  recurrence  of  the  retroversion,  the  organ  must  be  crowded 
over  forward.  With  the  uterus  in  this  position,  the  weight  of  the 
viscera  above  will  force  the  fundus  forward  in  the  direction  of  the 
least  resistance.     This  has  the  eifect  of  keeping  the  cervix  pressed 


ADJUSTING    PESSARIES. 


321 


against  the  posterior  -wall  of  the  vagina,  and  will,  in  time,  be  likely 
to  change  the  flexure  into  a  simple  version. 


Pessary  applied  for  retroversioa. 

The  extremity  of  the  pessary  going  into  the  cul-de-sac  should  be 
rounded  gradually,  and  not  made  too  narrow  in  proportion  to  its  length, 
unless  there  should  be  some  special  reason  for  doing  so.  The  utero- 
sacral  ligaments  become  sometimes  inflamed,  from  the  irritation  estab- 
lished by  a  badly  fitting  pessary,  resulting  in  a  condition  which  it  is 
difficult  to  relieve.  These  ligaments  are,  as  we  have  seen,  on  each 
side  of  the  uterus,  just  above  the  vaginal  junction,  and,  extending  to  the 
sacrum,  form  partially  the  sides  of  Douglas's  cul-de-sac.  Frequently 
inflammation  is  produced  by  injudicious  distribution  of  pressure  from 
a  pessary  so  curved  as  to  rest  against  the  uterus  just  at  its  junction 
with  the  vagina.  The  same  result  frequently  follows  the  use  of  a 
pessary  of  which  the  upper  end  has  been  made  somewhat  square,  having 
two  corners  which,  by  imbedding  into  the  tissues,  localize  the  pressure 
too  much,  and  produce  irritation  ;  also  by  forcing  the  ligaments  as  far 
apart  as  their  near  attachment  to  the  uterus  will  permit.  The  well- 
defined  and  thickened  edges  of  these  ligaments  are  often  found  to  be 
exceedingly  sensitive  to  pressure,  as  the  finger  is  passed  into  the  pos- 
terior cul-de-sac.  Should  this  condition  be  overlooked,  and  a  pessary 
be  introduced  without  some  proper  preparatory  treatment,  an  attack 
21 


322  PESSARIES. 

of  pelvic  cellulitis  will  most  likely  result.  To  remove  this  sensitive- 
ness, it  is  necessary  to  use  the  hot-water  vaginal  injections,  to  apply 
iodine  freely  to  the  surface  of  the  cul-de-sac  every  third  or  fourth  day, 
and  to  endeavor  to  gain  some  support  for  the  uterus.  This  condition 
of  the  ligaments  may  be  kept  up  for  an  indefinite  length  of  time,  if 
there  be  no  restraint  placed  on  the  movements  of  the  patient.  While 
on  the  feet,  the  weight  of  the  uterus  and  viscera  above  is  sustained 
chiefly  by  these  ligaments,  and  more  especially  so,  if  they  have  be- 
come shortened  by  previous  inflammation.  It  is,  therefore,  neces- 
sary for  a  limited  time,  that  the  patient  remain  chiefly  in  the  recum- 
bent position,  when  this  can  be  done  without  detriment  to  the  general 
health.  If  necessary,  as  a  temporary  expedient  to  allow  of  the  pa- 
tient's exercising,  the  needed  support  can  generally  be  supplied  by  a 
cotton  pessary,  in  the  shape  of  a  half-grown  mushroom,  placed  in  front 
of  the  cervix.  This  is  made  by  taking  a  square  pledget  of  damp  cot- 
ton, pressing  it  between  the  hands,  and  folding  the  corners  over  towards 
the  centre,  until  a  ball  has  been  formed  of  the  proper  size.  Then  as 
the  corners  are  held  between  the  extremities  of  four  fingers,  the  stem 
portion  is  formed  by  wrapping  a  cord  about  the  cotton  between  the 
ends  of  the  fingers  and  the  ball  portion.  When  well  formed,  saturated 
with  glycerine,  and  properly  placed,  this  will  make  a  useful  support  for 
simple  prolapse. 

If  the  patient  lies  on  the  back,  with  her  limbs  flexed,  and  has  the 
perineum  depressed  by  two  fingers  of  the  operator,  it  will  be  an  easy 
matter,  by  the  aid  of  a  pair  of  forceps,  to  introduce  this  cotton  pessary  ; 
and  if  it  is  of  a  proper  size  and  so  placed  as  to  avoid  making  pressure 
on  any  sensitive  point,  it  will  give  great  comfort  and  support  for 
hours. 

In  the  absence  of  the  posterior  cul-de-sac,  or  where  this  portion  of 
the  vagina  is  unusually  small,  retroversion  is  always  found.  This  is 
in  consequence  of  the  space  being  too  limited  for  the  cervix,  which 
can  only  press  forward  in  the  axis  of  the  vagina,  with  the  effect  .of 
throwing  the  fundus  into  the  hollow  of  the  sacrum.  This  class  of  cases 
we  find  among  young  girls  or  sterile  women,  and  it  is  a  condition  ex- 
ceedingly difficult  to  correct  until  more  room  be  gained  for  the  cervix 
to  lie  in  the  cul-de-sac.  This  space  can  be  gained  and  the  retroversion 
reduced  only  by  a  perfectly  straight  or  flat  pessary,  fitted  to  receive 
its  support  from  behind  the  symphysis.  Then  it  will  be  requisite  that 
the  instrument  put  the  vagina  sufficiently  on  the  stretch  to  can-y  the 
neck  of  the  uterus  so  far  into  the  hollow  of  the  sacrum  as  to  produce 
an  ante  version.     On  account  of  the  peculiar  form  of  instrument,  and 


ADJUSTING    PESSARIES. 


S23 


as  the  vaginfB  of  these  cases  are  always  small,  g;rcat  care  is  needed 
in  fitting  the  pessary,  and  watclifulness  afterwards,  that  it  does  not 
cut  into  the  tissues.  Particularly  is  this  care  necessary  in  fitting  the 
instrument  about  the  pubes.  We  here  find  occasionally,  a  difference 
in  the  curve,  on  each  side  of  the  symphysis,  so  that,  if  a  pessary  be 
made  symmetrical,  it  may  break  and  cut  into  the  soft  parts  covering 
the  lesser  curve.  In  these  cases,  with  the  vagina  small,  there  should 
be  no  sharp  angles  but  a  gradual  curve.  Frequently,  it  is  necessary 
to  bend  the  corners  downward,  to  correspond  with  the  roof  of  the 
vagina,  at  this  point,  and  a  depression  for  the  urethra  should  also 
always  be  made. 

The  shorter  the  vagina  (that  is,  from  deficiency  of  the  cul-de-sac), 
the  straighter  must  the  instrument  be,  for,  if  curved  too  much,  it  Avill 
rotate  and  remain  across  the  axis  of  the  canal.  A  straight  instru- 
ment has  to  be  Avider  in  the  middle,  in  proportion  to  its  length,  than 
a  curved  one.  The  widest  part  of  the  vagina  is  from  one  sulcus  to 
the  other,  while  the  lateral  walls  and  posterior  surface  of  the  canal 
form  a  concavity.  Consequently,  a  curved  instrument  should  be  made 
smaller  in  the  middle,  as  its  support  is  chiefly  derived  from  the  poste- 
rior wall  of  the  vagina.  It  is  a  very  common  occurrence  to  find  a 
pessary,  when  too  wide,  cutting  its  way  along  the  lateral  walls  of  the 
vagina,  at  the  bottom  of  a  deep  fold  which  it  forms  as  it  is  carried 
downward  from  the  pressure  above. 

For  the  purpose  of  illustrating  the  use  of  the  cotton  pessary,  it  was 
described  somewhat  out  of  place,  but  with  it  should  be  classed  the 
hollow  India-rubber  disk.  This 
disk,  of  the  shape  given  in  Fig. 
55,  but  a  little  larger,  is  made  of 
thin  rubber  and  inflated.  There 
are  certain  conditions  in  which  this 
form  of  support  will  be  frequently 
found  most  useful,  and,  whenever 
the  glycerine  is  not  particularly 
needed,  the  disk  will  answer  the 
purpose  better  for  continued  use 
than  the  cotton  pessary.  It  is  chiefly  useful  for  the  treatment  of 
cases,  when,  in  consequence  of  a  previous  attack  of  cellulitis,  there 
still  remains  too  much  tenderness  on  pressure  for  the  use  of  an  ordinary 
pessary.  To  avoid  making  pressure  on  the  urethra,  or  any  other 
point,  a  depression  can  be  made  on  one  side  by  passing  a  small  elastic 
band  once  or  twice  around  the  thickness  of  the  instrument.     This 


Fig.  55. 


Rubber  disk  pessary. 


324  PESSARIES. 

disk  may  be  placed  in  front  or  behind  the  uterus,  according  to  circum- 
stances. It  answers  for  aateversion  -when  placed  in  front  of  the  cervix, 
provided  no  tenderness  exists  on  the  anterior  wall ;  or  it  may  be  in- 
troduced behind,  in  the  posterior  cul-de-sac  if  large  enough,  and  if 
there  has  been  no  cellulitis  in  the  neighborhood.  I  have  used  the 
instrument  chiefly  where  cellulitis  has  existed  in  one  of  the  broad 
ligaments,  and  -when  the  inflammation  has  subsided  sufficiently  to 
render  it  safe  for  the  patient  to  commence  outdoor  exercise.  The  use 
of  the  disk,  in  these  cases,  will  prevent  the  uterus  from  sagging  in  the 
pelvis  while  the  patient  stands,  and  thus  protect  the  shortened  broad 
ligament  from  traction.  It  may  be  so  placed  in  the  axis  of  the  vagina, 
that  the  depression  made  by  the  band  shall  be  situated  in  such  a  way  as  to 
protect  from  pressure  the  thickened  ligament  which  had  been  inflamed. 
Or  the  instrument  may  be  introduced  across  the  vagina,  in  front  of 
the  cervix,  according  to  the  capacity  of  the  vagina,  and  the  amount  of 
thickening.  To  facilitate  the  introduction,  it  is  only  necessary  to 
compress  the  disk  between  the  fingers  after  it  has  been  lubricated 
with  a  little  soap  and  water.  Grease  should  not  be  employed,  as  it 
destroys  the  elasticity  and  rots  the  material.  The  offensive  discbarge 
from  the  vagina  produced  by  the  long  use  of  India-rubber  is  a 
serious  objection.  If  it  remains  in  the  vagina  for  a  length  of  time, 
pruritis  is  often  caused  by  it,  and  even  vaginitis  may  be  established. 
Anr  instrument  formed  from  this  material  should,  therefore,  be  only 
for  temporary  use,  or  until  a  better  substitute  can  be  found.  The 
irritating  effects  of  the  rubber  can  be  guarded  against,  if  the  patient 
Avill  take  the  trouble  to  remove  the  instrument  whenever  it  is  not 
needed  to  aid  her  in  exercising,  and  at  night.  As  soon  as  it  has  been 
removed,  it  should  be  carefully  cleansed  in  cold  water,  and  Aviped  dry. 
A  loop  of  cord  passed  through  the  open  ring  in  the  centre  of  the 
instrument  will  greatly  facilitate  its  removal.  By  degrees,  the  air 
will  escape,  so  that  the  instrument  will  become  partially  collapsed, 
but  it  can  be  again  easily  inflated  by  means  of  a  hypodermic  syringe. 
A  thickened  portion  can  be  readily  felt  in  the  side  of  the  disk,  through 
which  the  air  was  introduced  in  the  first  instance.  As  the  syringe 
will  have  to  be  refilled  several  times  with  air,  it  must  be  detached 
from  the  needle.  This  necessity  is  obvious,  since  so  many  additional 
punctures  would  allow  the  air  to  escape  only  the  more  readily.  While 
the  syringe  is  detached,  the  finger  should  be  placed  over  the  opening 
in  the  needle  to  prevent  the  escape  of  the  air  already  introduced. 

Under  no  circumstance  should  a  piece  of  sponge  be  introduced  into 
the  vagina  as  a  substitute  for  a  pessary.     Of  all  substances  which 


OBJECTIONS  TO  SPONGE  PESSARIES.  325 

could  be  employed  for  the  purpose  this  becomes  the  most  offensive. 
But  the  most  serious  objection  to  its  use  is  its  dilating  quality,  which 
will  in  time  expand  the  vagina  to  the  full  size  of  the  pelvic  excava- 
tion; and  it  ceases  to  give  the  needed  support  without  the  size  is 
increased  from  time  to  time,  besides  which  its  continued  use  destroys 
all  natural  support  and  elasticity  of  the  tissues,  so  much  so  that,  when 
full  dilatation  of  the  canal  has  taken  place,  no  instrumental  appliance 
will  any  longer  answer;  and  should  it  be  necessary  to  resort  to  any 
surgical  procedure  to  relieve  the  procidentia — a  condition  of  frequent 
occurrence — it  is  difficult  to  obtain  satisfactory  union.  I  have  fre- 
quently learned,  on  inquiry,  that  the  use  of  the  sponge  has  been 
recommended  by  physicians  "who  have  no  faith  in  pessaries,"  and, 
I  may  add,  by  those  who  are  unable  to  fit  them. 


326  ETIOLOGY    OF    UTERINE    FLEXURES, 


CHAPTER    XVII. 

ETIOLOGY  OF  UTERINE  FLEXURES. 

Tables  (XXIV.  to  XXX.)  showing  the  relations  of  flexures,  general  and  special,  to 
marriage,  celibacy,  pregnancies,  miscarriage,  menstruation,  etc.  etc. — Ante- 
flexures — Retroflexures — Lateral  flexures. 

It  would  be  difficult  to  account  for  the  diversity  of  views  entertained 
by  prominent  medical  men  regarding  the  origin  and  treatment  of  flex- 
ures except  upon  the  supposition  that  the  cause  and  effect  of  these 
troubles  are  often  confounded.  Let  us  see,  therefore,  if  we  cannot 
arrive  at  some  definite  knowledge  on  the  subject,  but  to  do  this  we 
must  go  back  to  the  beginning  of  menstrual  life,  and  study  the  initial 
stages  of,  and  the  subsequent  changes  in  the  difi"erent  forms  of  flexures. 
We  may  thus  be  able  to  analyze  symptoms,  to  separate  the  cause  of 
one  flexure  from  another,  and  to  appreciate  that  their  origin  varies,  and 
that  the  treatment  must  vary  with  the  form.  For  this  purpose  there 
will  be  presented  the  data  obtained  from  the  records  of  three  hundred 
and  forty-five  cases  which  have  passed  under  observation  in  my  pri- 
vate hospital. 

We  shall  consider  first,  flexures  of  the  cervix,  at,  or  below  the 
vaginal  junction ;  and  secondly,  those  of  the  uterine  body,  forward, 
backward,  and  lateral,  the  last  being,  in  all  probability,  but  devia- 
tions from  the  other  two  forms  of  flexure  of  the  body.  Table  XXIV. 
shows  that  one  hundred  and  eighty-two  women  were  found  Avith  flexure 
of  the  cervix,  of  which  sixty-two  were  unmarried,  one  hundred  and 
thirteen  sterile,  and  seven  were  doubtful  as  to  previous  pregnancy. 
There  Avere  ninety-one  flexures  of  the  uterine  body  forward,  consisting 
of  fourteen  unmarried,  forty-two  sterile,  and  thirty-five  fruitful  so  far 
as  to  have  been  impregnated.  Seven  unmarried,  nine  sterile,  and 
thirteen  fruitful  women  suff"ered  from  retroflexion,  in  all  29.  Forty- 
three  were  found  with  lateral  flexures,  of  which  number  six  were  un. 
married,  twenty-five  sterile,  and  twelve  had  been  impregnated. 

52.75  per  cent,  of  all  the  flexures  were  of  the  cervix,  and  47.24  per 
cent,  of  the  body  ;  26.37  per  cent,  of  the  Avhole  number  were  of  the 
body  forward,  8.40  per  cent,  backward,  and  12.45  lateral.  The  pro- 
portion of  unmarried  was  69.66  per  cent,  for  flexures  of  the  cervix, 


FREQUENCY    OF    FLEXURES. 


327 


and  30.83  per  cent,  for  flexures  of  the  body.  For  the  sterile,  59.78 
per  cent,  were  of  the  cervix,  and  40.21  per  cent,  of  the  body.  For 
the  fruitful,  10.44  per  cent.  Avere  flexures  of  the  cervix,  and  89.55 
per  cent,  of  the  body.  Thus,  of  all  women  with  flexures,  25.80  per 
cent,  were  unmarried,  54.76  per  cent,  were  sterile,  and  19.43  per 
cent,  were  fruitful.  The  proportion  for  the  total  number  of  all  flexures 
was  14.09  per  cent,  of  all  the  cases  of  every  description  under  obser- 
vation. 


Tadle  XXIY. — Flexures  of  the  Uterus. 


Flexures  of  the  uterine  body. 

0 

c 
© 

P. 

0 

27 
16.56 

76 
46.62 

60 
36.81 

Flexures 
of  the 
cervix. 

a 

"O    - 
0  X 

is 

0  " 

. 

% 

3 

0 
to 

cS 

a 

(B 

•3 

Percentage. 

To  the 
light. 

bo 

"S 
0 

<B 

<s 
ie 
a 

a 

0 

1 

1      '=0 

u  !   .5 

2     1       S3 

1^  ^ 
1  i  & 

62    69.66 
34.06    ... 

113   59.78 
62.18^   ... 

7   10.44 

3.84    ... 

14 

15-38 

42 

46.15 

3.5 

38.46 

15.61        7 
51.85  24.13 

7.88       4 
25.02  28. i;7 

4..;9i      2 
14  81    6.89 

4.12      17 

2.24 
7.40 

8.99 
22.36 

14.92 
16.66 

S9 
25.80 

189 

54-76 

67 
19-43 

Sterile 

22.22       9     4.76^      8 

55.2631.03  11.84  57.14 

51.79      1.3    19.40'      2 
58.33  44.82  21.66  14.28 

10.52  58.62 

Fruitful 

2.98     10 
3.33134.08 

Percentage 

Total 

Percentage 

91 

35.82 

26.37     29  j  8.40     14     4.05     29 

...     17.77'   •••   1  8.5°    •••    17-77 

8.40 

163 

47-25 

182  1   ... 
52-75 

345 

By  reference  to  Table  III.,  page  156,  Avill  be  seen  the  relative  and 
actual  proportion  of  the  unmarried,  sterile,  and  fruitful.  The  un- 
married with  flexures  were  8.01  per  cent.,  and  the  sterile  27.36  per 
cent,  in  excess  of  the  average,  while  for  the  fruitful  the  liability  to 
flexure  is  35.95  per  cent,  less  than  the  general  liability.  It  is  thus 
evident  that  the  woman  who  ha.s  been  impregnated  is  rarely  found  with 
a  flexure  of  the  cervix,  and  in  comparison  with  other  women  is  but 
little  liable  to  flexures  of  the  uterine  body. 

The  proportion  of  flexures  of  the  cervix  Avas  for  the  unmarried 
34,06  per  cent.,  for  the  sterile  it  was  62.18  per  cent.,  and  for  the 
fruitful  only  3.84  per  cent.  Now,  as  to  the  total  number  of  the 
married  Avomen  with  this  condition  of  the  cervix  94.16  per  cent. 
Avere  sterile.  My  convictions  are  that  the  proportion  is  eA^en 
greater,  since  I  have  never  observed  a  marked  case  of  flexure  of 
the  cervix  in  any  Avoman  Avho  had  gone  to  full  term.  In  a  total  of 
182  cases  Ave  find  only  seven  women  Avith  this  form  of  flexure  who 
Avere  supposed  to  haA^e  been  impregnated.  After  carefully  going  over 
the  records  of  these  cases,  it  Avas  found  that  in  five  instances  the 


328 


ETIOLOGY    OF    UTERINE    FLEXURES. 


f^ 


0^ 


'l^ 


fc. 


pi 

< 


•aSeiJi'Bax 

C-3  i-O  .—  O  ^ 
CO  C-1  r-   S  ^_ 

55  Cq  0»  N  r-1 

0 

^■8  a5u  85^J9AV 

c 

u-  —  O  C 

■^ 

C  O  CC  S  r-. 
•^  -f  CO  -!■'  -1- 

c\ 

C^  -f  ^  CO 

"  ^  ■  ■  ■ 

•sajnxag  h'b 
JO  aaqrann  in}0j. 

GO  vr> 



:  :  :  :  : 



•XIAJ80 

aT[j  JO  sajtixsg 
JO  jgqmmi  J'eioj. 

S  :  ;  :  : 

CO      •      •      •      • 

—  o 

■a 
o 
.o 
s> 

e> 
"5 

o 

c 

y. 

o 

•I-B^OX 

l'    0 

•qj9T  sq}  ox 

■      •      •      ■ (M 

.   Ov 

:  :  :  :- 

•jqgij  sq]  ox 

!:;-).! 

.    Ov 

'■      '■     -co      '• 

;  -4- 

•pjTSAiJlO'Bg 

;  r  i  1 

:    Ov 

:  :-  ;  : 

'.  t^ 

•pjBAiJOj^ 

:-  ;  :  : 

•^ 

"..^1  ;  r  : 

•xiA.ieo 
8-q:}  JO  ajnxaiji 

CT    •    ■    •    • 

??•••• 

c; 

CO      '     •      •      • 

CO    >? 

s 

rH        .       .       .       • 

-:• 

""^  i  i 

-*    ". 

- 

■  ■ 

""  i ;  i 

3^ 

s 

«^^  \  \ 

01  t^      -IMCO 

s;f 

>o 

-1  Tl  r-  «       ■ 

o 

■O  O     -1-1  M 

C5    " 
ff»   in 

--  :  :- 

«    4 

C  5=  -*<.-  t- 

CO    f^ 
1"  in 

« 

m  coco  (M  ni 

^    CA 

'^^  —  CO  CO  Ol 

CO    '^ 

12. 

-*  CO  :-        •       • 

"1 

c;  CO  —  ^  r-< 

'^^l 

d 

M  :  j  .  . 

-4- 

«      •       •       ■  r-l 

CO   "0 

o 

(M  !  :  ;  ! 

(M    ". 

c 

.s 

•     i 

o 

u 

.2  ^ 

r 
c 
E- 

3 

o 

^  ; ; ; :  :i  ;s,  1 

•S3-n.2 

s  &  o  o 
c  rf  a  o 

C—  o 

fc  ■>  S  ^  o  o 

i  '^  3  S  o  o 

•  c3 
c3  O 

.     1 

e 
•< 

0 

! 

■poijjT!aia0 

'                      1 

I 

•oiuois 

1 

FLEXURES    WITH    REFERENCE    TO    PUBERTY, 


329 


■^ 


X 
X 

pa 
< 


20  3.') 
19.40 
IS.OO 
24.00 

^ 

-!•  O        CO 

2s  a 

^S 

19.42 
21. .50 
19.00 
21.00 
20.. 50 

2 

0 

14.43 

12.00 
14  00 

'^ 

I 

ag§8S 

CO  r;  't  6  -f* 

yo 

1 

q 

MM 

S  : 

to  ■ 

S  : 

i  i 

t>-    .    .    .    . 

6 

t^    • 

:     : 

'.    '.    > 

Sg 

"  2 

0    • 

io     ; 

;  6 

1    :    !  ;0 

.    0 

:  :  :  :- 

0    • 

OS            1 

:  :-  : 

.   r^ 

:  :  :-  i 

.  '^ 

eq    • 

^      : 

'■  x     '•     '• 

.   ^ 

•    •  cq    ■    • 

;  06 

CO     ■ 

>o    • 
CO     • 

S     : 

to    !    .    . 

.  "* 

C*      ■ 

'ct    '■   '■    '■ 

.  f^ 

CO            • 

»-■;;; 

(M 

1 

CO        t 

:- ; : 

o 

j-i  ^ 

to        ' 

eo    •    •    ■ 

0 

"MM 

^f 

0  ? 

f-H  N     •      • 

0 

CCr-<     _■     j 

0 

CO          N 

1 

«5  °^ 

""  :  : 

0 
(M   in 

tNrH      1      1      1 

n  0 

0  ? 

0          ". 

1 

«0  ,-1     1  — 

-8 

;  :  i"" 

lO  t^ 

(N  CO  (N      ■  rH 

0  "? 

"^I    OS 

0    s 

-t    •    ^r- 

IM     j     •     • 

C 

";«5     J    1    j 

0       ". 

^^^  : 

o 

^^  :^ 

--  :  :  : 

00 

5          0 

;(N     I    •    ; 

o.f 

cq  ^ 

t~         " 

:-  :  : 

■o 

-  :  :-  : 

to  -f 

0      q 

c3  F  (D  o 

o  s  o  o 

Sf  5 

,  ^    ,      .... 

1             .    .        . 

§3 
c3 

1 

■ 

c 

O—  o 

■  a 

-J  o 

o  S 

S  "  S  ^  oo 

S2^-g55 
.2  ■"  3  «  o  o 

"c 
c 
E- 

a. 

s 
s 

i 
Q. 

) 

0  s 

0 

c 
a 
c 

) 

•saSBujBosiui     -se^BuaTJOsini         .sa^BUj^osini 

on  TJllAl                            pUTJ                                      V               ■ 

raasj  nnj  ^i       nije}  nnj  ox                     '   '^ 

•Xj'biui 

nns 

■Tuj^iuj^ 

330  ETIOLOGY    OF    UTERINE    FLEXURES. 

occurrence  of  a  miscarriage  had  only  been  suspected  hj  the  physician, 
while  in  but  two  cases  had  any  mass  or  form  been  seen  which  might 
have  been  the  product  of  conception.  It  is  believed  that  future  ob- 
servation will  establish  the  fact  that  the  existence  of  a  flexure  of  the 
cervix  is  to  be  accepted  as  proof  that  impregnation  had  never  taken 
place. 

On  comparing  the  proportion  of  different  flexures  of  the  body  to 
each  other,  it  will  be  noted  that  a  little  over  half  of  all  flexures  of  the 
body  were  forward,  for  each  class  of  women.  But,  on  the  other  hand, 
if  we  take  the  total  number  of  anteflexions,  it  Avill  be  found  that  the 
liability  to  this  lesion  is  in  the  proportion  of  15.38  per  cent,  for  the 
unmarried,  46.15  per  cent,  for  the  sterile,  and  38.46  per  cent,  for  the 
fruitful.  The  number  of  the  unmarried  suifering  from  anteflexion  is 
very  nearly  in  the  same  proportion  that  this  class  bears  to  the  total 
number.  The  sterile,  however,  are  18.73  per  cent,  in  excess  of  that 
average,  while  the  proportion  of  fruitful  Avomen  is  shown  to  be"  16.91 
per  cent,  below  it. 

Retroversions  are  shown  to  be  comparatively  rare,  constituting  but 
8.40  per  cent,  of  all  flexures,  and  but  17.77  per  cent,  of  those  of  the 
uterine  body.  The  relative  frequency  of  retroflexions  to  the  number 
of  anteflexions  is  very  nearly  in  the  proportion  of  one  to  three,  if  the 
comparison  be  made  on  either  the  total  number  of  all  flexures,  or  on 
those  of  the  body  alone.  The  proportion  for  versions  of  the  uterus  is 
quite  difierent,  since  the  posterior  displacement  has  been  shown  to  be 
even  more  commonly  met  with  than  ante  version.  Unmarried  and 
sterile  women  are  a  little  more  liable  to  retroflexions  than  would  be 
in  proportion  to  the  general  average,  while  fruitful  Avomen  are  some 
ten  per  cent,  less  likely  to  sufier  from  this  lesion. 

Lateral  flexions  are  shown  by  Table  XXV.  to  be  twice  as  frequent 
to  the  right  as  to  the  left,  among  the  unmarried,  but  with  the  reverse 
condition  for  the  sterile,  and  five  times  more  frequent  to  the  left  for 
the  fruitful.  It  is  shown  also  that  the  unmarried  are  less  liable  to 
this  form  of  flexure,  but  the  liability  is  twofold  for  the  sterile,  while 
that  for  fruitful  Avomen  is  about  the  same  per  cent.  beloAV  the  average 
as  that  for  the  sterile  is  above  it. 

The  average  age  of  first  menstruation  for  those  with  flexure  of  the 
cervix  Avas  14.06  years,  of  the  body  14.11,  and  on  all  flexures  14.08. 
The  aA'crage  for  those  with  this  lesion  of  the  cervix,  Avho  were  un- 
married, was  14.01  years,  and  of  the  body  13.92  ;  of  the  sterile 
14.09  years  for  ihe  cervix,  and  14.32  years  for  the  body  ;  the  fruit- 


FLEXURES  WITH  REFERENCE  TO  REGULARITY.     33t 

ful  averaged  13.85  years  for  the  cervix,  anl  13.91  years,  for  the 
flexure  of  the  body.  These  figures  give  but  little  indication  that  the 
age  of  puberty  has  any  bearing  on  the  form  of  flexures,  or  of  their 
existence  at  that  time.  The  average  age,  however,  both  for  those 
with  flexure  of  the  cervix,  and  those  Avith  flexure  of  the  uterine  body 
is  a  little  earlier  than  that  already  given  for  the  general  average  age 
of  puberty  ;  but  this  may  be  accidental.  The  delay  in  development 
for  the  sterile  woman  is  about  as  much  above  the  general  average  as 
the  age  of  puberty  for  the  unmarried  and  fruitful  woman  was  below 
it.  The  only  marked  diff"erence  from  the  average  age  for  those  with 
flexures  under  all  social  conditions,  is  found  among  the  women  Avho 
had  alwaj^s  miscarried,  and  had  never  gone  to  full  term.  The  num- 
ber is  small,  it  is  true,  being  only  seven  cases  of  flexure  of  the  cervix, 
who  were  supposed  to  have  miscarried,  and  sixteen  with  different 
flexures  of  the  body.  The  average  for  those  with  flexure  of  the  cer- 
vix was  13.85  years,  and  for  those  of  the  body  13  years,  and  for  the 
total  number  13.26  years.  Now,  the  average  age  of  first  menstruation 
for  120  women,  who  had  suffered  from  various  diseases,  but  had 
never  gone  to  full  term,  and  only  miscarried,  was  13.38  years ;  an 
age  far  earlier  than  the  general  average  for  all  women  of  which  these 
formed  a  part.  As  the  difference  is  decided  in  both  instances,  and 
even  so  great  as  one  year  for  those  with  flexures  of  the  body  who  had 
miscarried,  the  circumstance  can  scarcely  be  a  mere  coincidence. 

Different  degrees  of  regularity  are  found  to  exist  with  different 
flexures  of  the  body,  but  the  averages  for  those  with  flexure  of  the 
cervix  are  essentially  the  same  as  those  taken  upon  all  women  under 
observation,  and  given  in  Table  III.,  page  156.  A  comparison  made 
between  Table  III.,  containing  the  general  averages,  Table  XVI., 
containing  those  for  anteversions,  and  the  accompaning  Table  XXVI., 
for  those  who  suffered  from  different  forms  of  flexures,  will  present 
many  points  of  interest  for  the  student.  By  comparison,  it  is  evident, 
so  far  as  can  be  judged  by  the  test  of  the  woman's  regularity,  that 
flexures  are  formed,  as  a  rule,  in  after  life.  This  is  particularly 
striking  in  regard  to  retroflexions  ;  for  the  proportion  of  women  who 
were  found  in  after  life  with  this  form  of  flexure,  and  were  regular 
from  the  first,  is  much  larger  than  is  shown  to  have  been  the  case 
for  all  women  under  observation.  The  proportion  of  those  who  were 
regular  after  a  certain  time,  as  well  as  those  who  were  never  regular, 
are  also  more  favorable  than  those  given  in  Table  III.,  on  the  general 
average.      A    study  of  these  tables   will   also   point   out   a   closer 


332 


ETIOLOGY    OF    UTERINE    FLEXURES, 


parallelism  between  versions   and  flexures  ;   particularly  is  it  well 
marked  between  retroversion  and  retroflexion. 


Table  XXVI Condition  of  Menstruation  with  Flexures. 


Condition  of  menstruation. 

Unmarried.        Sterile. 

Fruitful. 

Total. 

i> 

o 

<B 

«ti 
C 

d 
u 

o 

'Regular  from  the  first  . 
Percentage    . 

Regular  afterwards 
Percentage     . 

Never  regular      .     .     . 
Percentage    .     . 

34 
64-15 

12 
22.64 

7 
13.20 

75 
77-33 

10 
10.20 

12 
12.37 

1 
50.00 

1 
50.00 

110 
72.36 

23 
15-13 

19 
12;50 

Total    .... 
Percentage , 

53         !       97 
34.86           63.82 

2 
1^31 

152 

m 
u 

o  ■ 
o 

< 

■Regular  from  the  first , 

Percentage    ..... 

Regular  afterwards 

Percentage    ..... 

Nerer  regular 

Percentage     

6 
42.85 

6 
42.85 

2 
14.29 

27              25 
69.23     j    78.12 

9       '         4 
23,07     1     12,50 

3                3 

7.69           9.37 

58 
68.23 

1 
19 

22.3s 

8 
9.41 

Total 

Percentage.     .     .     . 

14         I       39       1       32 
16,47          45-S8    1    37-64 

85 

a  ■ 
o 

■  Regular  from  the  first  . 
Percentage    . 

Regular  afterwards       .     , 
Percentage    .     . 

Never  regular      .     .     . 
Percentage    . 

5 
83-33 

1 
16.66 

7 
77-77 

2 
22.22 

12 
92.30 

1 

7.69 

24 

85.71 

3 
10.71 

1 
3-57 

Total    .... 
Percentage  . 

a 
21.42 

9     :     13 
32.14  ^  46.43 

28 

6 
y. 

o 

1-3 

'  Regular  from  the  first  . 
Percentage    .     . 

Regular  afterwards .     . 
Percentage    .     * 

Never,  regular     .     .     . 
Percentage    .     . 

4 

1 00.  CO 
.... 

.... 

14 

77-77 

2 
II. II 

2 
II. II 

4 

57-14 

1 
14.28 

2 
28.57 

7 
24-13 

22 
75"^.  86 

3 
10.34 

4 
13-79 

Total    .... 
Percentage  . 

1           4                18 
1       13-79           62.07 

1 

29 

CONDITION    OF    MENSTRUATION    WITH    FLEXURES.         333 

The  want  of  rcirvilanty  seems  to  have  heen  some  bar  to  fruitfuhicss. 
The  number  of  sterile  women,  and  of  those  who  had  been  impregnated, 
having  flexures  of  the  uterine  body,  were  about  equal.  The  number 
observed,  however,  may  be  considered  too  small  for  any  practical  de- 
ductions to  be  drawn  from  them.  But,  I  find,  that  of  the  total  number 
of  all  women  under  observation,  197  cases,  or  9.00  per  cent.,  had 
never  been  regular ;  of  these,  38.57  per  cent,  had  been  impregnated, 
and  35.53  per  cent,  were  sterile.  Although  the  number  of  each  class 
who  were  never  regular  is  practically  the  same,  yet,  as  there  were  in 
the  total  number  of  women  under  observation  more  than  twice  as 
many  fruitful  as  sterile,  the  proportion  of  sterile  is  in  excess. 

The  condition  of  menstruation  as  to  regularity  seems  to  have  but 
little  connection  with  the  amount  of  pain  experienced. 

It  has  already  been  shown  by  Table  VII.,  page  160,  that  of  2178 
cases  at  puberty,  13.63  per  cent,  had  pain  for  a  short  time,  at  the 
beginning  of  the  flow  ;  13.49  per  cent,  sufl'ered  pain  during  the  flow  ; 
while  72.90  per  cent,  were  free  from  pain.  Of  that  number  22.61 
per  cent,  of  sterile  women,  and  8.52  per  cent,  of  fruitful  women  had 
pain  at  the  beginning  of  the  flow.  Of  those  who  sufiered  pain  during 
the  flow,  25.29  per  cent,  were  sterile,  and  4.79  per  cent,  were  fruit- 
ful Avomen,  while  but  52.09  per  cent,  of  sterile  women  Avere  free  from 
pain,  in  contrast  to  86.67  per  cent,  of  those  who,  in  after  life,  proved 
fruitful.  Painful  menstruation  is  thus  not  only  an  indication  of 
sterility,  but,  we  shall  see  hereafter,  it  also  points  out  the  form  of 
flexures.  In  Table  XXVII.  is  given  the  condition  of  menstruation, 
as  noted  in  152  cases  of  flexure  of  the  cervix.  The  unmarried  and 
sterile  constitute  each  about  50  per  cent.,  and  there  were  two  women 
who  were  supposed  to  have  miscarried.  Of  the  total  number  of  these 
flexures,  59.86  per  cent,  sufiered  pain  at  the  beginning  of  the  flow, 
9.86  per  cent,  during  the  flow,  while  30.26  per  cent,  were  free  from 
pain.  Again,  it  will  be  seen  that  49.05  per  cent,  of  the  unmarried, 
and  65.97  per  cent,  of  the  sterile  had  pain  in  the  beginning  of  the 
flow;  7.45  per  cent,  of  the  unmarried,  and  11.34  per  cent,  of  the 
sterile  sufiered  during  the  flow  ;  while  43.39  per  cent,  of  the  un- 
married, and  22.68  per  cent,  of  the  sterile  were  free  from  pain.  Thus, 
we  see  that  with  flexures  of  the  cervix  pain  in  the  beginning  of  the 
flow  is  the  rule,  and  during  the  flow  the  exception.  For  the  absence 
of  pain,  in  a  certain  number  of  cases,  Ave  shall  hereafter  off'er  an  ex- 
planation in  another  connection. 

It  will  be  noted  that  more  than  half  the  number  of  married  women 
with  anteflexure  Avere  sterile,  a  circumstance  already  referred  to  and 


334 


ETIOLOGY    OF    UTERINE    FLEXURES. 


g 


5^1 
^ 

f^ 


s 


i^ 


a 
< 
S 
s 

02 

•IT!}OX 

c5n 

^  0      1 

CI 

4 

1^   in       1 

>o 

El 

J9J 

?  :         :  ;      :  : 

" 

§  : 

<5  : 

\6    '• 

0 

JO -ox 

_  0 

m8 

d 

eq 

CO  CO 

e-1 

CO 

Cl 

CO 

IB 

•;U93 

1    • 

CO    • 

0. 

VO 

§  : 

8  : 
0  ■ 

0 

vd 

"J- 

•S8S1!3 

JO  -o^i 

Id  ^ 

id 

-H 
r-l 

"?3 

OS 

0 

-H 

o> 

•}n93 
aOcC 

t^ 

g  : 

0 

q    ; 

6    ■ 

CO 

0 

:  :       "  :     :  : 

■S9S'B0 

JO  -OH 

CO 

.    .          -ti  d         .    . 

r-H  0            ;      . 

-+* 

o 

a 

a 
l> 
a 

o 

a 
c! 

» 

j9a 

:  ^ 

•  d\ 

•sas'Bo 
jo-oji 

c:  CO 

d 

0    . 

^  0 

^  0 
d 

CO  '"' 
CO 

CO     . 

"3 

u 

•:}TI9Q 

8  : 

\6    '• 

0 

•S9SB0 

JO  -o^i 

:  :         :  -.      :  ; 

rH  CO 
CO 

(mS 

CO     . 

•%uao 

J9tl 

1^ 

8  : 

Si 

1  • 

8  : 

q  : 

ro   '• 

Si  ■ 

•898133 

JO  -OK 

0 

(M§ 

CO  0 
CI 

r-<cS 
CO 
CO 

CO 
CO 

1-1  CO 

CO 
CO 

CO      . 

k 

•?U90 
J9J 

i  : 

g, . 

VD      • 

:  :        8  :      :  : 

0  • 

8  : 

•SgSTiD 

JO  -ON 

CO 
(M 

;   -. 

«S3 

■^  : 

:  :           d      •  • 

.  .           0      •  • 

Cl      . 

« 

« 

o 

M 

M 

!e 
O 

E- 
-<! 

« 

0 

Eh 

•^n93 
a9j; 

S5  : 

'•  ^ 

•sas'BO 
JO  -OM 

1M§ 
CO 

0^ 

CO 

0 

d 

CO 

en    . 

"3 

•}n93 
J9j; 

00      • 

4  : 

8  : 

t^ 

H- : 

•S9S'E0 

JO  -OK 

~  0            •    •        •    • 
0           •    .        .    • 

-'  : 

d 

^   : 

S 

•}n93 

J9J 

?  : 

8  : 

-4- 

'J- 

t^ 

•S9S'B3 

JO  -OK 

d 

5 

0     . 

■0 

0   . 

•}tI93 

CO      • 

^  : 

t^ 

.    !          -5-  .       •    • 

ro    ' 

•S9S'B3 

jo-oji 

CO 

<M      . 

:  :       '=d      :  : 

.  .          0      •  • 

to     . 

a 
n 

H 

Eh 
b: 
■<l 
Kq 

g^ 

S3 

C 
E^ 

D 

Bi 

1      H 

«; 
a 

1 

•^U93 
J9<I 

t^ 

CO 

'^0 

•S9S'B3 

JO  -OK 

CO 

-8 

'"  d 

§1 

0     . 
0      • 

q\  ; 

_  0 
0 

--IS 
«     •. 

VO 

0      • 

3 
"3 

u 

•}U93 

J9d: 

'1*    • 

8  : 

d  : 

0 

•S98'B3 

jo-o^ 

0 
0 

00 
00    • 

C1§ 

CC 

ts  0 

;5 

CO 

CO 

0         . 

'u 

IS 

•:(TI93 
J9cl 

r^ 

T  1 

CO     • 

t^    • 

^  : 
00  . 

0    ; 

-^ 

•898133 
JO  -ON 

CO  So 

t> 

CO 
CO 

^__ 

00     ; 

0 
d    • 

ro 

^0 

CO 

CO 

•?U93 

^  '• 

.  :        d  • 

0     • 

•  •698153 
JO  -OK 

0 

«g5 

CO 
CO 

"  ; 

'^  d 
0 

CO      . 

«  t=  s 

—  ji  0 

cj   H    0 

be 

d 

a 
•0 

d 

a; 
bo 

0! 

a 
a> 

bi) 

p.  g 
S  5 

_gPH 

1 

c 

"c 
E- 

(B 

0 
<u 

•^  0  : 

0  « 

.2  bo£ 

rt  C  » 

bo 

a 

3 

•3 

a 
'3 
p< 

bD 

:  » 

.  to 

a  c3 

■3  a 
p.  u 

s  i 

0 

1    _ 

C 

E-i 

ID 

bo 

OS 

i 
2 

•xtAJ-00  oqi  JO  Bsanxaii 

•sojnxou9inV 

CONDITION    OF    MENSTRUATION    AVITII    FLEXURES. 


335 


■♦'S          o  %■     en's 

2-       i  "i 

e^ 

e^i 

8  :       >S  :     =.  : 

m   ■           \o    *       M    ■ 

^g       ^S    -8 

:  :         .  .     8  • 
=  •          •  •     g,  • 

^ 

«    . 

fr  :        8  :    !2  : 

i^    . 

8  :        8  : 

1 

4 

•«• 

q    ; 

cs    . 

00              eo          t-T 

n               CO          ci 

CO      . 

o                  m           \ 

o 
o    • 

6    '• 

eg"" 
d 

« 

?  : 

M 

1 

1G.G6 

2' 
33.33 

o     . 

1-  o              <M  o        '^  O 

JO               d          ^ 

-c     • 

:  :        ;  :      :  : 

t^ 

'.     ^ 

o         •  ■      :  : 

"   : 

•*■     ; 

•  •        •  •     §  • 

8  : 
0  ■ 

.    .             .    •           o 
.    .            .    .          o 

71   ■ 

8  :        ;  ;      :  : 

8  : 
d    • 

:  :         :  :      :  : 

e-i    .             .    .        •    . 
o             ■    •        •    • 
o             .... 

CM      . 

8  :        :  :      :  : 

8  : 

r-<       .                    .      .              .      . 
O                   .      ,            .      - 
o                .... 

'-'  ': 

■      •         1 

.'  d 
^"- 

• 

::     ;:   ::  |   ;? 

'•    ■               m          d 

•  •        8  •      •  • 

m 

o 

:  :         ;  :     °  : 

?  : 

•  '•       "l      '•  • 

"^  : 

:  :        :  :    "g        ^  : 

8  :        :  :     8  : 

V 

D 

3  : 
6    ■ 

3 , 

1      . 

:  :         d  :     ^  :         ^  : 

0    .       o    •            ^    . 
M              in                   vo 

o             •    .          o 

e 

ei    . 

.    . 

:  : 

;  q 

t^ 

oi               d      ■" 

■  S5 

ci    • 

«                    CO              « 

°°    .            .    .       °    . 

8  •         :  :     f 

Si     '                  *      ■         VC 

b    • 

^  • 

CO                          •        •                     n-.' 

-    i 

-q         :  :    «§ 

>o             •    •          >r> 

0                     0-1- 

0    ■           0    ;      vo    • 

o 

N                          CI                   0 

^    •              -J-    •         0     • 

vq     ; 

1 
11.2S 

3 
42.S5 

3 

42.8.5 

d    •     ] 

O'                     i-i               CO 

-  :  1 

8   •     v?- 

:  :        o  :     1^: 

CO     • 

;      ;               fig         «g 

•    •              o          d 

»^    . 

-8       eg    wg 

■Z  z  -n      S    •  -1        -to 

^  .S      'C    ;  ^       C  r3 

ci  V-  o      .S    ■  a      '5  a 

O   g       -3     ;  cj         P.O 

.S  bet.    .S  ■  "     s  " 
r2.2        5  1 

'"With  paia  at  the  lio- 

gianiag  of  tho  (low 

Porcoutago  .... 

With  paia  duriug  tbo 
flow 

O 

1       1 

£ 

o 

o 

a 

(2 

:     i 

!  0 

.   to 

:  J 

•  a 

.•(^         1 

'0 

•S9.It 

1X9  gOJ 

isa 

•B9anx9[f  IBJOJB'I 

336  ETIOLOGY    OF    UTERINE    FLEXURES. 

confirmed  bj  the  figures  given  in  this  table.  With  this  form  of  flexure 
4.70  per  cent,  had  suffered  from  pain  at  the  beginning  of  the  flow, 
51.76  per  cent,  during  the  flow,  and  43.52  per  cent,  were  free  from 
pain.  The  number,  however,  who  suffered  from  pain  at  the  beginning 
is  too  small  for  the  proportion  to  be  accepted,  without  further  observa- 
tion, since  it  consisted  of  but  one  sterile  and  three  fruitful  women. 
These  cases,  it  may  be  assumed,  began  menstrual  life  with  flexures 
of  the  cervix,  and  the  body  of  the  uterus  became  involved  afterwards. 
This  table  shows  that  all  the  unmarried,  and  the  greater  portion  of 
the  sterile,  as  well  as  of  the  fruitful  women,  suffered  pain  during  the 
flow,  which  would  indicate  that  this  is  the  rule,  while  pain,  at  the 
beginning  of  the  flow,  is  the  exception,  in  anteflexures  of  the  body. 

The  number  of  retroflexions  is  comparatively  small,  but  the  propor- 
tion is  greatest  among  fruitful  women ;  and  absence  from  pain  at  the 
first  menstrual  period  was  the  rule. 

The  greater  proportion  of  those  who  suffered  from  lateral  flexures 
were  sterile,  and  over  half  the  number  had  pain  in  after  life,  either 
in  the  beginning  of  or  during  the  flow.  But,  of  the  total  number,  a 
larger  percentage  had  been  free  from  pain  at  the  beginning  of  men- 
strual life  than  was  shown  to  have  been  the  case  with  either  the 
unmarried,  sterile,  or  fruitful  women  sepa^rately. 

Table  XXVIII.  gives  the  average  length  of  the  menstrual  flow,  at 
puberty  and  in  after  life,  for  all  conditions  of  uterine  flexures.  The 
average  length  of  menstruation  at  puberty  was  4.76  days  in  all  cases 
of  flexure  of  the  cervix.  But  little  variation  existed  in  the  average 
time  between  the  unmarried  and  sterile.  As  there  were  but  two 
women  who  were  supposed  to  have  been  impregnated,  all  the  com- 
parisons made  will  be  between  the  two  other  social  conditions.  The 
average  length  of  flow  was  4.80  days  Avith  those  who  were  regular 
from  the  beginning ;  with  those  who  were  never  regular,  4.33  days ; 
while  for  those  who  became  regular  afterwards  it  varied  but  little 
from  that  found  for  the  whole  number.  When  there  was  pain,  the 
flow  was  prolonged  to  4.89  days,  as  compared  with  the  4.18  days  for 
those  who  had  no  pain. 

The  average  length  of  the  menstrual  flow  in  after  life,  for  all  cases 
of  flexure  of  the  cervix,  was  4.62  days.  The  time  became  shortened 
with  both  the  unmarried  and  sterile  women,  but  more  markedly  so 
with  the  former. 

The  duration  of  flow,  at  the  beginning  of  menstrual  life,  averaged 
4.90  days  for  the  total  number  of  those  Avho  suffered  from  anteflexure, 
and  there  was  but  the  slightest  variation  from  this  average  for  either 


MENSTRUATION    WITH    FLEXURES.  387 

social  condition.  Those  -who  were  regular  from  the  first  menstruated 
4.97  days,  and  when  regular  afterwards,  5  days.  As  in  flexures  of 
the  cervix,  the  same  decrease  in  the  average  duration  is  to  be  noted 
for  those  who  were  never  regular.  When  attended  with  pain,  the 
length  of  flow  was  slightly  increased  above  the  average.  Where  pain 
occurred  at  the  beginning  of  the  flow  the  average  duration  was  4.89 
days  ;  with  pain  during  the  flow  the  time  was  increased  to  4.97  days  ; 
while  the  average  was  4.87  days  for  those  who  were  free  from  pain. 
It  will  be  shown  by  the  next  table  that,  in  comparison  with  flexures 
of  the  cervix,  the  menstrual  changes  in  after  life,  with  anteversions, 
were  more  marked  as  to  quantity  tlian  duration.  The  average  on  the 
total  number  is  essentially  the  same  in  after  life  as  that  found  for 
flexure  of  the  cervix,  with  the  same  general  diminution  in  the  length 
of  the  period.  This  change  is  more  marked  with  the  sterile,  sufiering 
from  anteflexures,  while  among  the  unmarried,  with  flexure  of  the 
cervix,  the  average  length  of  the  period  was  much  shortened. 

Women  who  suff"ered  in  after  life  from  flexure  of  the  uterine  body 
backward  averaged  5.02  days  for  the  length  of  the  first  menstrual  flow. 
Where  they  had  been  regular  from  the  first  the  average  was  5.12 
days,  and  when  regular  afterwards  it  Avas  found  to  be  4.75  days. 
For  those  who  were  never  regular  the  number  of  retroflexions  is  too 
small  to  be  noted,  but  the  rule  is  for  the  flow  under  this  condition  to 
be  much  shorter  than  the  general  average.  On  the  total  number  of  all 
cases  with  retroflexion,  the  average  length  of  the  first  menstrual  flow 
among  the  unmarried  was  3.66  days  ;  for  the  sterile,  5.33  days;  for 
the  fruitful,  5.50  days.  From  some  unknoAvn  cause,  the  average  for 
the  unmarried  is  far  below  that  for  either  of  the  other  conditions. 
Those  who  suffered  pain  only  in  the  beginning  of  the  flow  averaged 
5.25  days  ;  when  felt  during  the  flow  it  was  5.33  days  ;  and  for  those 
who  had  been  free  from  pain  the  average  was  4.09  days :  thus 
showing,  as  in  other  cases  of  flexure,  that  the  existence  of  pain  is 
always  accompanied  by  an  increase  in  length  of  the  menstrual  flow. 
In  after  life  the  average  length  of  flow  for  the  unmarried  was  but 
3.33  days  ;  for  the  sterile,  4.55  ;  and  for  the  fruitful,  5.30  days;  and 
for  the  total  number,  4.64  days.  It  will  be  noticed  that  (from  some 
accidental  cause,  it  is  supposed,  as  the  number  is  so  small)  the  length 
of  flow  for  the  unmarried  continued  in  after  life  below  the  average  of 
either  the  sterile  or  fruitful,  although  the  difl"erence  was  not  so  great 
as  we  have  shown  to  exist  at  puberty. 

The  length  of  the  menstrual  flow  in  after  life,  for  each  social  con- 
dition, became  less  than  that  existing  at  puberty.  But  the  fact  is  a 
22 


338 


"UTERINE    FLEXURES 


S. 


§ 

•"Si 

s 


^ 


"Si 


8 


•mo^jo 

OD  -1 

tDcq 

1>CD 

COrH 

0  CO 

s§ 

r^  -f 

t~  CO 

CO  c: 

i 

t[;Su8I  -AV 

■*  ^ 

^  rf 

^  1" 

ri--JI 

-J.  m 

-f  Tf 

Tt.  rf 

•*  Til 

•jsqranu 

f-H       •       * 

o     j     j 

f       \      \ 

2  \  \ 

rti      •     '• 

CO     •'     ■ 

CO      '■      '. 

•  O 

Cf-CO 

■C  O 

ira  0 

1010 

s 
a 

13 

•XnjqitiJj 

^  o 

-t  -t* 

-*  rP 

Tf  -f 

'^Tf-.ti 

"'■'•i^ 

o-j  ^ 

o;  o 

1-1  Ol 

10  W3 

r-i  CO 

1^  t^  t-- 

r-iCO  O 

•9XIJS?S 

«=^^- 

'"'  rlJo 

"^-^-^ 

™-#  Ti< 

'i-  i-H 

'^^•-*- 

"^rl^Ti; 

"-*-* 

-<.l^ 

CO  1~- 

-H^'*' 

.10      . 

_^lOT(l 

"^  ^<-#' 

^co-.d 

'^  -*;  -p 

"^  "d  -f' 

:■*  ! 

"^  -i'^ 

■sSv.iOAV 

.  m  1-1 

■  C  O 

!  :S 

'co  -c 

•  o  o 

■  o  o 

■f  o 

•rH  O 

.  ■--  0 
•C-l  0 

:^§ 

\-ei9u9o 

!'*  -* 

:«'im' 

•  •"" 

.  -f-* 

.(N.-I 

,TJ<  -+ 

.f^ 

.  -*<T)< 

•jaqintin 

CR      •      • 

(N  ■  • 

CO      •      • 

Ol      '■      '■ 

rH      :      '• 

■*      '.      '. 

CO      ■      • 

CO       •       • 

I'BIOi 

■   ■     i 

00 

> 

•injltnj^ 

CO  CO 

-JiCD 

eo  >o 

C  O 

coo 

0  0 

ICCO 

iz; 

•eiua^s 

o-# 

.  o 

'"'      !-3< 

Ol  r-. 

Tf    CO 

CO  CO 

-f  IM 

.lO      • 

o  o 

•  0    • 

•^  0 

•pauaBinnj^ 

oa  O  "O 

lO       -Tl" 

:  ^' 

-+  o 

»o  "rf 

X  <x> 

■-  CD 

.<»  CO 

.  iOrH 

.0(M 

'.CC  o 

Xtijanso 

•  -*  o 

*  "^  o 

••^  m 

•f  -f 

■  lO  CO 

'  -r  -t 

•-|<-^»' 

•■0-* 

•jeqrann 

l-H        ■       • 

(M      •      • 

o    •    ■ 

CO       •      • 

1— <    •    ■ 

in   :  ; 

t,    ■    ; 

2  :  : 

c  o 

0  0 

o>o 

i^ 

•ITij^inij 

i-l'^O 

rH      •=; 

^  >o  o 

■N==.<= 

^  lOl^- 

c3 
03 

^  o 

•  'O 

t^  -^ 

.  O 

.  o     . 

o  o 

1^  0 

M<CO 

3 
be 

•an-iaqs 

^  CD  O 

^to  O 

^«o 

o    •  'T 

.  CO      . 

^CD.CJ 

OOCD 

q;  Oi   CO 

O   T(l 

^  o 

Tf   ■* 

r-i       •  ^ 

•o    • 

-*  CO 

Tf    0 

-*  tH 

CO 

CO  o 

.0    . 

—1   0 

•paiwerauj^ 

t-°-*. 

>o      ■  "'' 

(M      .■« 

.0    . 

Tf  "O 

•   « 

i-H        •  -H 

•  lO      • 

•*  o 

n   rH 

.O  r~ 

.  o  o 

CD  rH 

.  t^  CO 

.1^  Oi 

.  a  t^ 

,r-l  -f 

.  c  i.-o 

,  05  t-' 

•jsqinnn 

•-(<,,< 

•^■n 

•t)<  -P 

■-C-H 

'O 

•lO  -*< 

•  -).-,. 

•-J<  tC 

o     •     • 

^    .    . 

§  :  : 

O      ■     • 

S  :  : 

0    •    • 

a 

u 

WOJ, 

r^ 

.  o 

.  O 

IM  ^  O 

^O  CD 

t-  0  0 

,r,cDco 

•injjmjd; 

rH       -O 

r^°.= 

(N  ~  "i 

■  ■* 

•Tt< 

■*  o 

T)<   Tf 

10  »o 

t~S;g: 

'ragg 

lO  ■=>  o 

.en    . 

t^coco 

0^  S 

t^lN'CS 

■sius'is 

5?t-t~ 

^cooo 

Sqco. 

3 

bo 

-!f  ^ 

T)<    O 

■*•* 

^-^ 

••^    • 

»o  -t* 

0  •I' 

IC  Tji 

S"^ 

^,ss 

28S 

.<M      . 

O  CO 

.  CD      . 

CO  CD 

•peuiBoinn 

CO". -•; 

.  ^      . 

Z£)    ^   '~^, 

.  CO      . 

lO  ^ 

■*  >o 

coo4 

■*  Tjl 

•  -f      • 

CO  tC 

*  -t    • 

T*"  -* 

i 

: 

y, 

fe 

w 

m" 

m 

m' 

•ji 

^ 

M 

.„■ 

m 

•  m 

^ 

Tl 

■a 

•d 

T) 

t3 

13 

l-a 

t,  >^=s 

>>ta 

J-  fc^ta 

o  >.=s 

>^c5 

:  >,  s 

^  >^=a 

o"S  is 

r.  ^ 

t:  u 

:t:  & 

St:  ^ 

III 

^11 

°  ^  3, 

fell 

3X1   « 

y.  3C: 

Hph-< 

Ph  < 

'bi)- — '^ 

:cu-i 

-*-*  (»- 

C  *" 

•"  o  ^ 

bn   "     H 

OJ    « 

^^   « 

2-^  =* 

a  J  "i 

•JS    =^ 

<„ja  =« 

5r„g 

•c^,S 

.2tJ,| 

t,  -f'S 

5  r,  a 

bijo 

2  U)? 

°l' 

"SSI 

-S-n 

P^iJ  tj 

a.  a  -^ 

oj    <D  t^ 

^^  d 

a  n,  3 

.9  a;  ? 
'3  br,  S 

a?2 

Bo  2 

o   ^>   =1 

■5  iijt! 

0  brjj 

a  «  g 

3    be- 

^gs 

^?*S 

•t:2a 

Ch  c4  2 

^2S 

•i^  2  a 

«2d 

j:(  »  OJ 

"3  S  c 

•3  S  2 

0  ^  ^ 

•"  "  a 

»  >  a 

§5  = 

i^" 

^4*^ 

1^' 

Y 

•xiAJoa  oq:j  jo  ed.inx 

aid; 

•Xpoq  eqi  JO  soanxoi; 

)iuv 

IN  REFERENCE  TO  MENSTRUATION, 


339 


■^ 


n 


Ol  CO  o 

in  •* 

to  CO 

to  CO  CO 

CO  CO 


o  o 
^  o  o 


.  CO  -**  ,  C-l  t 


_,  o  o 
'^  o  o 

;i^  -f  r-; 

o  o 
^  o  o 

C:  CO 

-t<  CO 

CO  o 

co'«.<= 

o  o 

c^  o  o 

lO  o' 

c^  o 

CO  CO  o 
"  CO  CO 

t^  o 

■o  <».  R 
CO  CO 

^  :  : 

o   >>  ^ 


.S  o  r; 

c3   tot. 
p.  C5  w 

.a  «  o 


5g'.2 

^  t-  d 

r5  a 


rf  -  -^ 
a._2   - 

S  ^  ^ 

o  tc  — 
K   :J  2 


H     S' 


^  £  a 


o  f  g 


•jtpoq  9qi  JO  sojnxoijoajaa; 


c  o 

«5  -J< 


OS  >o 


o  o 

(  O  O        1^  o  o 
(N  CO*  CI  TO 


;  O  CO 
•IC5-* 


.  UO  -V 


.CO  Ol 

.  cc  o 


o  >%5 

a  <D  f 


—  t*  ^ 


?ia 


<n  p^  --; 


;^  0) 


«^2 


i"^-     .2'^- 


&■ 


at,^ 

::^A 

S  g-2 

a  a-Z 

p.  «    OJ 

,c   ®   rJ 

6?2 

5  tc— 

o  «  o 

£5^ 

fo 

!<,« 

•Xpoq  em  ;o  ssjnxag  \TiXQ-^-eT_ 


o  o 

^  o  o 

r-:co 

coq=; 

>n  Tf 

c  o 
-f  '~  'T 

CO-)*' 

T*<  '"^  « 
^  I>-  c= 

CO  o 

-H  ^  -2 

CO  'l* 

o  o 

^  O  C3 

o  o 

0^1  =  "= 
CO  lO 

.-1  1(5 
^  t- t-; 

"OCO* 

b-     •     • 

310  UTERINE    FLEXURES 

remarkable  one,  that  the  average  duration  in  after  life  should  be 
essentially  the  same  for  flexures  of  the  cer\dx  as  for  those  of  the  body, 
either  forward  or  backward. 

The  average  length  at  puberty,  on  all  cases  of  lateral  flexures,  was 
4.58  days,  and  was  essentially  the  same  for  the  unmarried,  sterile,  and 
fruitful  Avomen.  In  after  life  the  flow  for  the  unmarried  was  increased 
to  6.75  days  ;  for  the  sterile  it  became  lessened,  and  again  increased 
with  the  fruitful  women. 

If  the  general  averages  as  given  in  Table  X.  page  167,  under  the 
head  of  menstruation,  be  accepted  as  standards,  it  will  be  seen,  that 
under  all  conditions,  both  at  puberty  and  in  after  life,  the  length  of 
menstruation  is  much  less  for  those  who  have  flexures  of  the  cervix. 
As  a  rule,  the  contrary  is  the  case  for  flexures  of  the  uterine  body, 
for  the  averages  at  puberty  are  much  higher  than  the  general  ones, 
but  in  after  life  the  difference  is  not  so  great. 

In  this  connection  the  fact  must  not  be  forgotten  that  the  duration 
of  the  menstrual  flow  is  always  lessened  in  proportion  to  the  amount 
of  pain  sufliered.  This  has  its  bearing,  in  indicating  the  existence  of 
flexures  of  the  cervix  at  the  time  of  puberty,  and,  if  accepted,  it  is  of 
equal  importance  to  prove  that  those  of  the  body  are  formed  in  after 
life.  The  changes  in  menstruation  after  puberty,  when  flexures  have 
existed,  are  presented  in  Table  XXIX.  These  are  treated  of  under 
two  heads,  as  regards  the  length  of  flow.  In  the  first  two  divisions 
are  grouped  those  in  Avhom  no  change  in  the  length  of  the  period 
occurred,  although  the  quantity  became  altered  in  those  of  the  second. 
The  duration  became  shorter  for  those  forming  the  third,  and  length- 
ened for  those  in  the  fourth  division ;  while  in  both  sections  the 
quantity  had  undergone  some  change.  Menstruation  remained  un- 
changed, in  every  respect,  from  what  it  was  at  the  beginning,  in  47.37 
per  cent,  of  all  cases  with  flexure  of  the  cervix.  Thus  there  were 
forty  cases  where  the  flow  was  normal  as  to  quantity,  with  an  average 
of  5.04  days'  duration.  Twelve  cases  were  always  too  free,  as  they 
had  been  from  the  beginning,  but  the  time  remained  unchanged,  and 
lasted  6.41  days  ;  while  with  sixteen  other  cases  the  flow  was  always 
scanty,  lasting  but  3.12  days.  In  this  group  of  cases,  where  no 
change  took  place  in  after  life,  the  average  length  of  normal  menstrua- 
tion for  the  unmarried  was  4.40  days,  and  for  the  sterile,  4.85  days. 
Again,  with  44  cases,  or  28.94  per  cent.,  forming  the  second  group, 
the  time  remained  the  same  as  at  the  beginning,  but  the  quantity  be- 
came either  increased,  lessened,  or  irregular  in  after  life.  The  aver- 
age duration  of  flow  for  this  class,  it  will  be  seen,  was  4.23  days. 


IN  REFERENCE  TO  MARRIAGE.  841 

We  find  this  result,  that  of  the  -whole  number  of  flexures  of  the 
cervix,  7G.18  per  cent.,  consisting  of  the  first  and  second  groups,  re- 
mained in  after  life  the  same  as  to  the  length  of  menstruation,  but 
■with  a  certain  number  of  cases  the  quantity  became  changed.  The 
third  group,  consisting  of  17  cases,  or  11.11  per  cent,  of  the  whole, 
was  formed  of  those  with  whom  the  duration  of  the  period  became 
lengthened,  while  the  cpiantitj  either  increased  or  lessened.  The 
average  duration  of  the  whole  group  in  after  life  was  6.23  days. 
The  fourth  group  consists  of  19  cases,  or  12.50  per  cent,  of  the 
whole,  in  which  the  time  became  shorter  in  after  life,  and  the  quan- 
tity was  also  changed.  The  average  length  of  the  period  was  3.26 
<lays  for  this  group. 

It  is  shown  by  Table  XXIX.  that  with  only  11  cases  of  anteversion, 
or  12.91  per  cent.,  forming  the  first  group,  the  menstrual  flow  re- 
mained unchanged  in  after  life.  But  if  the  second  group  be  included 
with  the  first,  it  will  be  found  that  with  51  cases,  or  60  per  cent.,  the 
length  of  flow  remained  unchanged  after  puberty.  Table  XXX.,  as 
a  summary  of  Table  XXIX.,  demonstrates  that  the  changes  in  quan- 
tity are  more  marked  with  anteflexion  than  with  any  other  form  of 
flexure.  It  is  shown  that  with  nearly  one-half  of  all  the  cases  of 
anteflexion  the  period  becomes  lessened.  This  proportion  would  be 
even  greater  at  a  later  period  of  life,  since  the  rule  is  that  the  flow  is 
at  first  increased  in  quantity  but  afterwards  becomes  less.  A  further 
consideration  of  these  tables  would  present  but  little  additional  inte- 
rest to  the  general  reader,  but  the  student  will  find  many  suggestive 
points,  for  the  elucidation  of  which  additional  observations  might  be 
profitably  undertaken. 

The  time  of  marriage  seems  to  have  had  but  little  bearing  on  either 
class  of  flexures,  or,  at  least,  none  where  there  existed  flexure  of  the 
cervix.  The  chief  point  of  note  is  the  fact  that  the  average  age  of 
marriage  was  a  little  later  than  the  general  one.  Either  extreme  of 
age,  however,  may  have  had  an  indirect  bearing.  For  instance,  the 
average  age  of  marriage  among  the  sterile  women  with  lateral  flexures, 
was  19.20  years,  and  for  those  women  who  had  been  impregnated  it 
was  25.75  years.  Among  those  who  had  been  sterile,  there  were 
seventeen  flexures  to  the  left,  and  the  average  age  of  marriage,  as 
shown  in  Table  XXV.  page  328,  for  these  women  was  17.11  years. 
This  is  the  lowest  average  of  any  one  class,  yet  a  high  one,  since 
several  women  were  somewhat  advanced  in  life  on  the  one  hand,  and 
on  the  other,  the  greater  number  w^ere  much  below  the  average  given, 
one  having  been  married  at  fourteen  years  of  age.     In  eight  of  these 


342 


UTERINE    FLEXURES 


'^ 


s 


% 


5>s 
8 


8 


X 
X 

pa 


>^^ 

•Aiog  joitjSna'j 

^           -.           °.      1   ^!       ' 

^t 

•sas'EO  JO  "0^ 

S     :       £     :       "     : 

g  : 

Lenotii  op  Flow  Lessened, 
WITH  THE  Quantity  either 

"3 

•Aiou  JO  Tu^na-j        :    f^  :      :    ^  :      i    =:  : 

•SOSBO  JO  -0^ 

=      :  :    "^      :  :    1-1      :  : 

2^ 

•Avog  joiijSiiai 

.     c   .       .       .   . 

0 
0  • 

-r 

-r 

•sasBD  JO  -0^ 

:      :  :    '"'      :  3      :      :  : 

0 

1    ® 

i 

•Aiog  joTiiSaai        ;     :  :     :     :  :     :     •  ■    1     •  • 

•BOS'BD  JO  -OKI 

:::::;:::          :  : 

•Aiog  JO  t[)Snai 

o                   a                   o                c)           I 

•sasiia  JO  'oj; 

O            :"->[>            ;CO        r-l            I   xn 

00  tx 

0 

C=3 

a  a 

■<  :- 

3 

•AiOp  J0Tl}3n9'J 

'.            '.     '.           '.        '^      '.           '.            '.      '. 

'      to    ' 

S  : 

•sasKO  JO  -osc 

ca      :  :    •-'      :  :      :      :  ; 

•Aiog  jonjiruai   ,     :     :  :     ."     :  :     :     :  : 

•sasBO  JO  "oj; 

§  2 

iJ  S 

•Aiog  joqiSna-j 

;     o    ;       ;       ;    ;        ;       ;    ; 

0  : 

I-l  CO 

•sasBo  JO  -0^    ;    '^      :  c      :      :  :      '■      '■  '• 

s 

l-l  p 

•AiogjOTijSnai     !       :     |    :       '•     %    ■       '•       '■    '■ 

«  : 

•sasBo  JO  -OX         •=       '•  '?    ^       '•  'T      '•       '■   '■ 

s  3. 

,  3 

a  :.,  =s 
IB  C  a 

E  is  - 

K  <!  a 

o  ;;  -« 

fc  ^  a 
=  e  £• 

^  =  5 
c  a 
!5  3 

iJ  ;< 

^ 

•Aiog  jonjSuai           •     ^-    •       •     '^    •       •       '■   '■ 

?i  : 

B 

•SaSBD  JO  -0^ 

2    :  :  ?i    ;  i    :    ;  ; 

a   . 

■AVogjoqjSnai 

c                  o 
;      o    ;        ;      '-'■    ;        '.        '.    '. 

•6    '             vi 

g  : 

•sasBO  JO  -oj^ 

^      -8    ^      :8      :      ;  ■ 

0^ 

M 

to  T3 

.3g 

■Avog  JO  qjSnai 

o    _         .      'S    .         .         .    . 

;^   . 

«                   ^ 

-T-' 

■sasBD  JO  '0^1 

'^     : «    '-'     :  ti.     :     :  : 

CD    0 

a  5 

■AS-og  joqiSuai 

CD                      O 

:    ■-=  :     :    ^  :     :     :  : 

lO                         -1- 

•sasBa  JO  -ox 

m      ;  0     o      ;  q       :      :   : 

1  en     '^        .  ^d        ■        •    •' 

|i 

6.5 

o  a 

>- « s 

E^  §  5 
»  5  2; 
■<  a  =     , 

C    ^    M 

IB  ft 

u 

«^  ■ 

r 

•As.og  joqjSuai 

(M                           t^                           O 

;      (M    ;        ;      to    ;        ;      c    ; 

«  : 

•sasBO  JO  -o^si 

a 

•Avog  joqiSnai 

;      o    ;        ;      «    ;        ;        ;    ; 

o5           '     m    ' 

e<3 

•sasBO  JO  -oy 

.00                        •    "            •            •      • 
«                           00 

o 

o 

•Avog  joqjSuai 

f    • 

t-                  <o 

to 

•sasBO  JO  -o^yj 

^0 
N  -0 

-z 

•Aiog  jomSaai 

=                         «5                        0,-5. 

:    ^  ;     :    o"-  :     :    <=  :       ■=?  ; 

J 

•sas^a  JO  -ox        ;2      '•  ?    S      = "?    -,      :  "•        31  "• 

.-a-       •jsa-       -.aa- 

•  -^  0    •         •  f  0    ■         •—s- 

:  if--^  0     :  S*""  «     :  ^-  ® 

rngti")      KpcSU)      w-SU) 
o^afl      c_:;;;-cj      <i;^-d 

iafi  iiiil  s»|| 
^igS  HI?  HU 

Sr;-(Jo         fe<1o         fc5<!o 
•oiSnii?     -eiiaeis     •ItiJ1l"-'.J 

0 
Eh 

0 
to 

0 

'                                     1 
"xiAJoa  eqj  jo  sajnxai  j 

IN  REFERENCE  TO  MENSTRUATION. 


343 


■^ 


I— ( 


4.64 
4.53 

4.75 

CO 

<o 

3.33 
5.30 

moo 
t-  o  S 

to  -«■  o 

4.96 

-r         •           o>         •           ci         ■ 

rt            .               CO             •               CO            ■ 

CC      i 

to            .               (35             ■               CO            • 

Cl     • 

•fl-  so  t. 

0 

C                          JJ                          0  1                      c      . 

(N    '                r!                    —                 CO 

:      :  :     :    %  :     :    %  : 

CO 

CO 

<^      ;  ;    —      ;  ;    '^      '.  '. 

O  m 

;       IT"*       ;   ;     *'       ^   ; 

to    -J- 

•r 

■      :  •      :    8  :      :    §  : 

q    : 

;    ;     ph       ;    ;     e»       ;    ; 

CO   6 

:      :  :      :    =.  :      :      :  : 

q   : 
'l' 

-8 

o          1     < 
;    ;        •        :    ;        ;      o    ;           ' 

to'          '     ' 

2    . 

vO 

H  vq 
vo 

:      ::    ^      :  j"      :      '■  \ 

;     :  :      :     :  :    ^      :  3 

ci                    rj                    CO 

^'  . 

o                    o           i      o     . 

;  •      :    °  ;      :    °  :    1    °.  • 

■    ■        ■      ci                   t-^                CO 

CO  o 

'"  q 

eo  CO 

s 

0                     in                    -n      1            g 
ei        ;incn        ;cio        ;cj«>5 

.      .  .    ^      -  8    ^      :  8        o  ? 
:      :  .            .  o'            •  d           ^y 

:«^ 

-J" 

1 

171                               O 

;        ;    ;        ;      ci    ;        ;      q    ; 

to 
o 

q  : 

en     ; 

C-3 
CO 

:     :  :    "^      :  :    '"'      :  ': 

'-'  ? 

CO 

o 

:      !  ;     ;    °  !      '.      ■  ■ 

:      :  :    ^'      :  8      :      :  : 

d^S 

:      :  :      :    °.  :      :    §  : 

S  : 

■       •         r-              •    CO        M             ;«3 

•    •  •        ■  s        -s 

CO   ■*• 

;        ;    ;        ;      q    ;        ;        ;    ; 

rn 

o§  : 

CO 
CO 

;        ;    ;      o        ;  vo      eo        ;  ro 

vo 

:      ;  :    "      is      :      :  :    |    "8 

r-  c^     ;       j      M 

1-                            O                            <M                        00 

;      t-    ;         ;      q    ;         ;      05    ;            i<    ; 
-r    '         '>--:'         '      CO    '            'i' 

:    q  :     :    §  :     :    ??  : 

r:                    -.D                    lo 

0 

ao      ;  ;     0       .  .'     ^      ;  ; 

O    0 

^  t^ 

"      :  :    =*"      :  :    ^      :  : 

"   ^ 

1 

CO 

000 

;      q    ;        ;      q    ;        ;      q    ; 

CO    ; 

CO 

:      :  :      :      :  :      :    q  : 

8  : 

d\ 

rH        ;  CO     1-1        ;  CO     ri        ;  ro 

'    CO                        "    ro                        ■    ro 

CO  a 

:     i  :      i      i  i    "      :8 

:    0  :     :    §  :      :    ^  : 

1- 

CO    ; 

o                   c                   c 

°.  : 

0 
0 
-1^ 

0        ;  t^     rH         ;  CO      t-        \  -T 

o 
CO  m       1 

CI        ;  0      ci         ;  8      ^        ;  0 
'■6                 •  d                 •  d 

o  -J- 

;^rt 

CI 

:    q  :     :    ci  :      :    S  : 

■r^                                   10                                   -t- 

0 

-V   q 

:    S  :      :      :  .     :    ^  : 

o     . 

c=  o  o 
o  =  o 

•~  o  o 

^  1 

^      :3      :      :  ;    ^     :S 

.  o        -        ■    ■                •  d 

■=1  1 

l-H  rH  C<l 

1"                                                                           CC 

ra     -        j 

CO                         O                          o 

;      q    ;        ;      q    ;        ;      tc    ; 

^  : 

-1^       1 

0                              -t* 

-v 

'•'      ;  ;     ;      ;  ;    '^      '.  \ 

-f      i 

~      -  ;    oi      :  ;    o      ;  : 

0 
o    t^ 

C4  -■  CO 

CO 

0 

c    ; 

§  :     1 

:      :  :      :      :  :      :    S  : 

o 
q    ; 

:°.q 

ci  -* 

to 
co' 

■^ 

CO 

\     \\     \    \\   -     -A 

rt  q^      i 

\    \\    \    w  -    ■.% 

.h8     ( 

0 

;■*« 

0 

:    §  :     :      :  :     :    §  : 

c 

•    o  :      •      :  ;      :      •  : 

o    . 

q   ; 

q  :o 

0 

CO 

-      :  8      :      :  :    -      :  3 
■  S,      ■      ■  ■             'Si 

-1 
S  ■ 

rH      ;rH 

CI          j 

:    o  :     :     :  ;      ;    ==>  : 

to                                              ^ 

04 

:    °  :     :    S  :      :    ^^  : 

co'                       c=                        l! 

qq  : 

s 

O                                                        0 

CO      ;  io     •      :  :    «      :  fp 

.  r^        .          .     .                   .  r^ 

fO                                             vo 

CO    t^ 

o       ;  8     oq       :  3     -c       ;  3 
.  lA              .to              .0 

QO    8 

d 

■"■  ^    I 

CO 

;ja  d    ;        ::a  a    ;        ;£  a    ; 

:  to:5  o      t  '^•.n  ffl      ;  ^w  o 

mSrftO       oja^;,)       toa-jv^ 
12-.5a       S^ia       Se^ia 

^pp    ^|s§    ^|S3 
oggs     =  =  25     ot:23; 

o>.^       o>"'^       o>~f-i 
fe5-=1o          !2;<;o          fc«1^ 

•j^ran;i      -siiiaig     -xnjjin.ij 

o 

;j3  5     ;         ;£  a     ;         ;£  a     ; 

•  ^.-2  o          ■  '^'■%,  ■o          ■  ^■n  o 
aJflrfS)       ccgllbo       '/:gdto 

^"aj      =-.2=^      «.2=J 
c^Q^fc^a      e3Q-*^a       ^Qbiia 
^?«S§      ^|a?      ^|§§ 
cgog       ogog       ocog 
.  ®  a  n          .  o  a  «          .  o  a  <r 
o>"i-'       c>-t_'^       o>.    '■< 
z;<  o         ^<:  o         fc«^  o 

•.ittmnji      -311.1313     'injiinjj 

c 
E-i 

o 

1  1 

t.4 

S.2 

il 

5 

3 

0 
E-c 

1 

1 

•sa.inxag 

•ssansegsjnv                            11 

■saanxoBoaiOH 

1          1 

344 


UTERINE    FLEXURES 


a 
a 

m 

uoijipnoo  qo'Ba 
aoj  -jnao  aaj 

-*  !>1  t-  O  tC 
CJ  O  CJ  :s  C-. 

aj  o  50  c:  CO 

<j<  ^  o  -r  -i- 

!>;  !>;  r;  --  t;;; 

CO  CO  '^'  O  CO 
^         (M  CO 

1 
1 

CO  GC'  CO  00 

t3  CO  q  CO 
S5  M  S  w 

•snoptpnoo  ^-e 
no  pousd  JO 

O  CO  *0  CO  sc 

■^ 

(N  O  -F  O  1^ 

r-  c:  CO  —  CO 
lO  eii  o  ^  -*' 

-r  <:'  o  CO  -!i< 

-* 

O  CO  O  CO 
Or-t  <=  CO 

id  eot^co' 

=3 

•S3St!D  JO 

J9qninu  ^Ejox 

-•  ffl  ^  lO  53 

o 

00  r-i  0<M  CO 

S 

00  rH  CO  O  r^ 

(N 

OO  CO  CS  CO 

s 

PI 

:3  a  d 

=  -  o< 

■uopipuoo  -qo-Ba 
joj  •}ns3  idd 

\ 

.  i-tco  o 

.  T^  CX)  t- 

•  C-;  o  -f' 

•     '(M  t~     ■ 

:  :2^ 
■  :^15 

•pot.iod  JO 

.      .COCO  O 

-1^ 

:  !N  t^  CO 

;e5co^ 

CO 

;    ;  !>■'  CO    ; 

QO 

;    ;  cc  CO 

O 

•SOSBO 

JO  jaqmnij^ 

'■      •  O  O  rt 

to 

'•      -0030 

CO 

1 

I      *  CM  o      [ 

t~ 

i 

•    •  eo^ 

«- 

Length  of  period 

lessened,  willi  the 

quantity  either 

•ivinSajxi 

; ; ':- : 

«3 

:  1  t  ;  CO 

«    1 

CO     . 

i 
i 

•pas'BaJoiii 

1 

;  r  i  i 

r^    w 

;  ^  :  : 

1  :  :  :  :  : 

1 

•poudssai 

;  I  i-  : 

f 

!    I  o    . 

:  :  to  ■ 

C^ 

I         1          !   TJH          . 

t-^ 

o 

.2  "  ° 

p. 'So 

lit 

tea  S3 
^  a 

•jB^n^a-i-iI 

'.'.'.     '-Si 

M 

•pauasaai 

:  :  ':-  : 

VO 

t    '     ■  CO     '; 

— 

s  1 

d 

L 

:  'i  :  :  :  ;  : 

' 

■ 

•pas-Ea.ioni 

!     .  O     •     • 

6 

;      1  C3      '•      • 

r ;  "• 

t^   '  .  .      .  . 

d 

•a 
S| 
"=  -a  o 

iSa 

pa- 

a 

•noijipuooqo-ea 
JOJ  -jnao  ja<i 

to 

— 

CO  CO  t-   CI  CO 
-O  C-.  CO  CO  CO 

•o  I-!  •-'  o  <: 

^      CO  n^ 

~  CO  [^  O  CO 
O  t-.  uo  CO  t- 
:/^  .**  cc  CO  -^ 
CO        (N  (M 

jco  t^  t*  c:5    , 

.         COIN  0^  CD      . 

:    icot-t t-icj  • 
|„<Nc 

': 

•pouad  JO 
qiSuax  aS'E.iaAy 

O  r-  ^_  ^_  '^. 
O  CO  >0  -j;  CO 

O  CO  1^  a  CO 

CO 

(M  O  CO^  O 
O  O  COrJ*  O 
Tj<  o  "O  ■*  "*' 

CO  r-i    CO   •^   — 

O 

ococoo    . 
Oi-i  CO  o     . 

•deoco-*    : 

g 

-* 

: 

•sasBO 
JO  jaqninii 

-*  oj  <a  o  o 

2 

r-  CO  CO  CO 

o 

CO  coco  CJ    • 

^ 

Length  of  period 

nnchangod,  but  tho 

quantity  became 

either 

•j'ExuSajJi 

.... 
....  13 

" 

!    I    ■  CO 

1 

ro 

i 

! 

■panassai 

'.  !  ;  o  ■ 

.      .      .  (M      . 

2 

q 

:  ':  "^  : 

t^ 

-     t(M     • 

•pas'Bajioui 

!    Irs    :    . 

^ 

'.^    '.    '. 

1 

- 

'.  o   •    • 

t^ 

t^fi   '   ■ 

CO 

Teriod  unchanged 

as  to  time  and 

quantity,  being 

from  tho  beginning 

•A)n-Bos 

■.  o    I    .    . 

d 

''■r\\\ 

-  :  i  i 

r^ 

:  CO  •  ■  : 

d 

•aaij  oox 

1  !  (M  ;  ! 

^ 
t^ 

'■    '-rn    '•    '• 

m 

;- : ; 

l^ 

■  "^  !  i 

\6 

•^■Bnijo^ 

^  i  i  !  ! 

: 

"  i  :  :  ; 

f  ; ; : ; 

00  t  1  .  . 

c 

;'3    ;    ; 

;  «j  :  ; 

:2  :  : 
:  o  .  . 

■  a    .    . 

t  ^"    t    I 

•  "      b. 

"3 

.a   ; 
■A  : 

d  : 

o    • 
«>  a 
|.2 
a^ 

£  d 

£  o 

"a    •    • 
;  o   ;   ; 

: «»  :  : 

■  a    .    . 

s§Se 

X  Eh  ►J  i; 

1 

«>  : 

g : 

S.g 

S  a 

1 
1 

u 
c 

;  «>  *  ; 
■£  '•  * 

"a 
o 
E- 

«>  : 
d  : 

o   . 

o  d 

to  o 

a  ^ 

i 

1 

i 

u 
C 

;  o   ;   ; 
:  S  :  : 

'.  1^    '.    I 
.  o    .    . 

.  d    .    . 

'.  Ui     '.      ', 

.  a  «^ 
>.£  a  a 
"■'•'  °  te 
3  o  «  £ 
u  o  «i  £ 

"3 
1 

o    , 

d  : 

o    • 
o  a 

'  >^  2 

'XIAJ03 

eq? 

JO 

'vojnxo 

BO?c 

V 

1      •B9jnx9B0j;9a 

■SDjnxop  x*-'91B'I 

IN  REFERENCE  TO  MENSTRUATION.  345 

cases  evidence  of  previous  cellulitis  was  detected,  a  condition  very 
frequently  found  with  lateral  flexures.  The  highest  average  age  of 
marriage  for  any  particular  class  was  found  in  those  who  had  gone  to 
full  terra,  generally  but  once,  and  had  had  miscarriage  frequently 
afterwards.  Seven  of  these  had  anteversions ;  three,  retroflexions  ; 
and  six,  lateral  flexures  to  the  left.  The  average  age  of  marriage  for 
these  cases  was  28.43  years,  and  this  comparatively  advanced  age 
was  doubtless  an  exciting  cause  of  miscarriage  and  its  consequences. 

The  average  age  at  time  of  the  first  examination,  for  all  cases  of 
flexure  of  the  cervix,  was  24.80.  For  the  unmarried  it  was  23.42 
years;  for  the  sterile,  25.02  years.  The  duration  of  the  sterility 
was  3.21  years.  There  were  but  two  cases  of  supposed  pregnancy 
in  which  miscarriage  had  taken  place  at  an  average  of  8.50  years  pre- 
vious to  the  first  examination. 

The  average  age  of  those  with  flexures  of  the  body  forward  was  27.94 
years.  The  unmarried  averaged  23.97  years  ;  the  sterile,  28.78  years, 
and  the  fruitful,  31.28  years.  The  average  length  of  time  since  mar- 
riage was,  for  the  sterile,  7.61  years  ;  and  since  the  last  pregnancy, 
for  those  who  had  borne  children  it  was  7.63  years  ;  for  those  who 
had  only  miscarried,  6.20  years ;  in  two  cases,  due  to  criminal  abor- 
tion, four  years  had  elapsed. 

The  age  of  those  suffering  from  retroflexion  averaged  30.68  years  ; 
of  the  unmarried  29.22  years  ;  of  the  sterile  24.25  years  ;  and  of  the 
fruitful  34  years.  The  average  length  of  time  since  marriage  was 
3.44  years  in  the  sterile  ;  since  the  last  impregnation,  for  those  who 
had  gone  to  full  term,  7.46  years  ;  for  those  who  had  miscarried  5.83 
years  ;  and  after  one  case  of  criminal  abortion  it  was  five  years. 

The  average  age  of  first  examination,  for  the  total  number  with 
lateral  flexure,  was  31.37  years  ;  that  for  the  unmarried  being  33.50 
years;  for  the  sterile  30  years;  and  for  the  fruitful  31.40  years. 
The  time  since  marriage,  for  the  sterile,  was  6.86  years  ;  one  woman 
had  gone  to  full  term  and  remained  sterile  13  years.  In  those  who 
had  miscarried  5.66  years,  on  an  average,  had  elapsed,  and  in  one 
case  of  criminal  abortion,  the  woman  had  not  been  again  impregnated 
during  five  years. 

With  all  flexures  of  the  body  the  average  age  at  the  time  of  first 
examination  was  25.88  years  for  the  unmarried  ;  for  the  sterile, 
28.57  years  ;  and  for  the  fruitful,  32.35  years. 

It  is  a  remarkable  fact,  that  the  average  age  at  which  relief  was 
sought  should  bear  a  direct  proportion  to  the  frequency  of  the  form  of 
flexure.     This  would  indicate,  if  no  other  proof  existed,  that  flexure 


3-16  riERIXE    FLEXURES. 

of  the  cervix  Tvas  a  condition  of  puberty  and  early  life,  since  relief  is 
sought  at  the  earliest  age  ;  that  anteflexures  follow  soon  after,  while 
retroflexures  and  the  lateral  ones,  being  less  common  and  found  in 
about  the  same  proportion,  are  developed  in  later  life. 

As  forming  a  part  of  the  history  of  flexures  it  will  be  of  interest  to 
record  the  supposed  causes  of  disease  as  given  by  the  patients  them- 
selves. In  22  sterile  women,  with  flexure  of  the  cervix,  who  had  com- 
menced their  menstrual  life  free  from  pain,  five  cases  are  recorded  as 
ha^-ing  sufiered  sooner  or  later  after  marriage,  from  dysmenorrhoea 
during  the  flow.  The  same  result  followed  in  one  case  from  exposure 
to  cold,  in  another  instance  from  the  use  of  a  sewing  machine,  and  one 
of  the  fruitful  had  been  Avell  until  the  time  of  her  supposed  miscar- 
riage. Among  the  unmarried,  23  cases  had  been  free  from  pain  at 
the  beginning,  and  attributed  their  dysmenorrhoea  in  after  life,  in  two 
instances,  to  the  effects  of  cold;  in  two  to  over-study  while  at  a  board- 
ing-school :  and  another  considered  it  the  result  of  a  fall. 

All  of  these  cases,  when  first  seen,  had,  in  addition  to  the  flexure  of 
the  cervix,  hypertrophy,  and  more  or  less  disease  of  the  body,  with 
some  degree  of  flexure  also  above  the  vaginal  junction.  This  would 
leave  thirty-three  cases,  or  over  two-thirds,  Avho  were  free  from  pain 
in  after  life,  too  small  a  number  to  be  of  great  statistical  value,  but  it 
will  serve  as  an  indication  of  the  fact  that  a  certain  proportion  of  flex- 
ures of  the  cervix  are  unattended  by  dysmenorrhoea  during  after  life 
unless  other  disease  be  superadded. 

Of  eighty-five  patients  who  suffered  from  anteflexures,  sixty-four 
attributed  the  origin  or  aggravation  of  their  dysmenorrhoea,  to  the 
following  causes  :  Eighteen  sterile  women  suffered  after  marriage  from 
venereal  excess,  and  eight  from  the  effects  of  cold.  Twenty-four 
fruitful  women,  the  total  number  of  those  who  had  been  free  from  pain 
or  at  least  had  suffered  only  at  the  beginning  of  the  floAv,  suffered  from 
the  following  causes :  Five  from  natural  labor,  two  from  tedious  ones, 
and  one  from  instrumental  deliv-ery  ;  twelve  had  miscarried,  two  were 
the  victims  of  criminal  abortion,  two  were  worse  after  falls,  and  one 
from  fright.  Seven  unmarried  women  took  cold  and  suppressed  the 
menstrual  flow,  three  were  taken  sick  from  over-study  at  boarding- 
school,  three  suffered  from  falls,  and  one  from  dancing  at  the  time  of 
the  period. 

Had  it  beeti  possible  to  have  obtained  the  facts,  I  am  satisfied  that 
the  unknown  causes  of  anteflexure  among  the  sterile  and  a  portion 
of  the  fruitful  women  might  have  been  found  in  the  means  taken  to 
prevent  conception  hi  early  married  life  by  the  sterile,  and  by  those 


CAUSES.  347 

who  had  already  borne  children;  some,  doubtless, were  the  result  of 
ill-assorted  marriages,  and  mental  disquietude,  from  which  the  nervous 
system  may  readily  become  involved,  with  an  impairment  of  local  nu- 
trition through  the  medium  of  the  sympathetic. 

Of  those  with  retroversion,  five  sterile  women,  who  had  been  in 
previous  good  health,  grew  steadily  worse  after  marriage  ;  one  suf- 
fered from  exposure  to  cold,  two  were  taken  sick  at  boarding-school, 
and  for  the  one  remaining  there  was  no  cause  of  disease  known. 
All  the  fruitful  women,  with  retroflexion  afterwards,  were  the  worse 
for  impregnation.  Five  were  sick  after  childbirth,  seven  after  mis- 
carriage, and  one  after  the  production  of  a  criminal  abortion.  An 
attack  of  cellulitis  followed  childbirth  in  three  cases,  and  in  each 
instance  after  the  miscarriage  and  abortion.  One  unmarried  woman 
was  taken  sick  at  boarding  school,  another  from  exposure  to  cold,  and 
two  cases  suiFered  after  falls.  Thus  the  supposed  causes  of  retro- 
version in  all  but  three  cases  have  been  given.  Three  sterile  women 
with  lateral  flexures  became  sick  immediately  after  marriage ;  one 
fruitful  woman  after  childbirth,  three  after  miscarriages,  and  one  after 
a  criminal  abortion.  One  unmarried  woman  suffered  from  exposure 
to  cold. 

Flexures  of  the  cervix  have  their  origin  about  puberty,  or  shortly 
afterwards,  by  the  balance  being  lost  between  the  relative  growth  of 
the  body  and  cervix.  From  the  earliest  development  of  the  uterus, 
as  a  rule,  until  pregnancy,  some  degree  of  anteversion  exists.  With 
the  uterus  in  this  position,  the  neck  cannot  be  developed  to  its  full 
length  without  forcing  the  cervix  forward  in  the  axis  of  the  vagina, 
in  the  direction  offering  the  least  resistance.  As  the  body  of  the 
uterus  lies  forward,  the  cervix  must  become  bent  upon  itself  at  or 
near  the  vaginal  junction,  and  thus  the  flexure  is  formed.  This  must 
take  place,  as  has  already  been  stated  in  a  previous  chapter,  or  the 
uterus  will  become  retroverted,  the  result  being  determined  by  the 
fulness  or  absence  of  the  posterior  cul-de-sac  of  the  vagina.  AVhen 
the  cervix  is  small  enough  in  diameter  to  be  readily  bent  upon  itself, 
the  flexure  is  formed,  but  if  the  contrary  be  the  condition,  and  the 
cul-de-sac  be  small,  retroversion  of  the  organ  will  occur.  As  the 
growth  is  not  always  completed  at  the  time  of  the  first  menstrual 
period,  a  woman  may  begin  with  flexure  of  the  cervix,  and  afterwards, 
from  retroversion  have  retroflexion.  With  flexure  of  the  cervix,  the 
neck  always  becomes  longer  in  after  life  than  it  was  at  puberty,  as  a 
consequence  of  being  croAvded  forward  in  the  vagina,  and  such  a  con- 
dition will  then  frequently  produce  retroversion. 


3-18  UTERIXE    ILEXURES. 

With  this  form  of  flexure,  the  rule  is,  as  regards  pain,  that  it  exists 
prior  to  the  appearance  of  the  flow  and  then  ceases,  or,  at  any  rate, 
becomes  much  less.  If  the  degree  of  flexure  is  slight,  there  may  be 
an  absence  of  pain,  with  as  little  feeling  of  discomfort  as  any  female 
may  experience  at  such  a  time,  or  the  pain  may  not  come  on  until 
after  the  flow  has  become  fully  established.  When  pain  occurs  in 
early  menstrual  life,  and  lasts  through  the  flow,  with  or  without  a 
flexure  of  the  cervix,  a  condition  of  the  circulation  already  exists  in 
the  body  of  the  uterus  which  later  is  likely  to  give  trouble  and  to 
result  in  anteflexure. 

From  the  congestion  attending  menstruation,  the  flaccid  and  elon- 
gated cervix  becomes  thickened  and  shortened,  so  that  the  uterine 
canal  is  then  made  nearly  straight,  with  the  cervix  strong  enough  to 
resist  the  pressure  of  the  posterior  Avail  of  the  vagina.  Therefore, 
the  dysmenorrhoea  existing  just  at  the  beginning  is  relieved,  and,  if 
the  flexure  be  not  very  marked,  impregnation  frequently  takes  place 
shortly  after  marriage.  But  the  chances  of  impregnation  are  lessened 
rapidly  after  the  first  year  of  married  life,  since  disease  of  the  uterine 
body  and  ovarian  irritation  are  likeh^,  in  time,  to  be  established  as 
Nature's  protest  against  the  childless  condition  of  the  married  female. 

We  have  no  other  condition  where  menstruation,  being  painful  at 
the  beginning,  is  relieved  so  promptly  when  the  flow  becomes  estab- 
lished. This  symptom  may  be  regarded  as  characteristic  of  a  simple 
uncomplicated  flexure  of  the  cervix.  It  has  been  shown  that  8.52 
per  cent,  of  twelve  hundred  and  thirty-one  fruitful  women  sufiered  in 
early  life  from  pain  at  the  beginning  of  the  flow.  This  percentage 
may  be  assumed  as  the  one  in  which  impregnation  is  likely  to  have 
taken  place  with  flexures  of  the  cer\dx.  We  have  no  other  means 
of  arriving  at  any  conclusion  on  this  point,  since  a  flexure  of  the 
cervix,  in  my  experience,  is  never  found  after  a  female  has  gone 
to  full  term.  I  have  observed  hypertrophy  and  anteflexure  of  the 
uterine  body  to  come  on  in  after  life,  from  some  exciting  cause, 
when  the  flexure  of  the  cervix  would  gradually  disappear  as  this  later 
condition  became  established.  This  new  morbid  state  completed,  the 
sterility  would  continue,  since  there  was  then  a  greater  bar  to  impreg- 
nation than  previously.  In  some  cases,  when  the  disease  of  the  body 
did  not  become  quite  so  extensive,  a  degree  of  flexure  would  still 
remain  in  the  cervix.  Menstruation,  in  this  condition,  would  then  not 
only  be  painful  before  the  flow  came  on,  but  would  continue  so  through- 
out, and,  if  a  sufiicient  amount  of  ovarian  disturbance  had  been  set 
up,  the  pain  would  be  even  more  severe  after  the  flow  had  ceased. 


RETROFLEXION.  349 

If  Ave  are  able  to  draw  any  deduction  from  the  analytical  history 
of  anteflexures  which  has  been  furnished,  it  is  unequivocally  to  the 
eifect  that  this  condition  has  its  origin  after  puberty,  and  observation 
indicates  it  to  be  the  result  of  obstructed  circulation  from  impaired 
nutrition.  Painful  menstruation  during  the  flow  may  occur  under 
other  conditions,  but  it  is  never  absent  in  any  form  of  flexure  of  the 
uterine  body,  either  forward,  backward,  or  lateral.  Whenever  a 
female  has  been  free  from  pain  during  menstruation  in  early  life,  and 
anteflexion  has  been  discovered  afterwards,  it  is  my  firm  conviction 
that  in  such  a  case  the  uterus  was  in  a  normal  condition  at  puberty. 
Where  pain  has  occurred  at  this  early  period  in  the  beginning  of  the 
flow,  becoming  intensified  with  its  progress,  and  lasting  until  it  has 
ceased,  a  flexure  of  the  body  has  not  existed  necessarily,  but  a  con- 
dition which  engendered  the  flexure  afterwards.  With  pain  at  this 
period  of  life,  just  at  the  commencement  of  the  flow,  and  relieved 
when  fully  established,  a  condition  exists  which  has  been  already 
explained. 

Retroflexions  are,  I  believe,  deviations  from  a  previously  existing 
retroversion.  While  they  are  always  aggravated  by  an  obstructed 
circulation,  as  in  the  case  of  other  flexures  of  the  uterine  body,  the 
exciting  cause  is  generally  inflammatory  action,  not  in  the  organ  itself 
but  in  the  connective  tissue  of  the  pelvis  and  ligaments  of  the  uterus. 

After  a  moment's  consideration,  it  will  be  evident  that  the  uterus 
may  be  retro  verted  to  a  point  at  which  the  broad  ligaments,  being 
already  on  the  stretch,  may,  by  inflammation,  become  shortened  so  as 
to  produce  the  flexure.  This  action  may  be  also  aided,  once  shorten- 
ing of  the  broad  ligament  exists,  by  inflammation  in  the  utero-sacral 
ligaments.  When  a  point  in  the  version  has  been  reached,  at  which  the 
anterior  wall  of  the  vagina  can  no  longer  yield  to  the  upward  pres- 
sure of  the  cervix,  any  contraction  of  these  ligaments  will  increase 
the  degree  of  retroflexion.  Since  inflammation  of  the  neio-hborino- 
cellular  tissue  of  the  pelvis  is,  I  believe,  almost  always,  if  not  invari- 
ably, an  accompaniment  of  retroflexion,  these  ligaments  become  neces- 
sarily more  or  less  involved. 

Before  dismissing  the  subject  of  retroflexion,  I  must  express  the 
conviction  that  this  lesion  is  by  no  means  so  commonly  found  as  is 
generally  supposed  by  the  profession.  Thickening  on  the  posterior 
wall  of  the  uterus  from  obstructed  circulation  in  a  case  of  retroversion 
is  frequently  mistaken  for  it.  This  condition  is  not  necessarily  accom- 
panied by  cellulitis,  and  disappears  rapidly  after  the  uterus  has  been 


350  UTERIXE    FLEXURES. 

placed  in  a  position  ^"here  the  circulation  can  again  be  properly 
carried  on. 

Lateral  flexures,  as  has  been  already  stated,  are  thoucrht  to  be 
formed  in  after  life  as  the  result  of  shortening  of  the  broad  ligament, 
from  inflammation  on  the  side  of  the  flexure,  a  version  having  pre- 
viously existed  either  forward  or  backward.  I  have  never  met  with 
any  e\idence,  conclusive  enough  to  settle  the  point,  that  this  form  of 
flexure  was  ever  congenital.  Since  the  number  of  versions  to  the 
left  are  found  in  about  the  same  proportion  as  cellulitis  occurs  on 
that  side,  in  comparison  with  its  frequency  to  the  right,  I  have  become 
confirmed  in  the  opinion  that  lateral  versions  are  the  consequences  of 
inflammation. 

The  length  of  menstruation  becomes  shortened  in  after  life  in  all 
forms  of  flexure,  but,  as  a  rule,  this  change  takes  place  very  gradu- 
ally. The  tendency  is  for  the  quantity  also  to  become  less,  but  the 
first  change  is  marked  generally  by  an  increase  of  flow,  which  di- 
minishes gradually,  and  this  course  is  the  most  marked  among  the 
sterile  women.  With  flexure  of  the  body,  atrophy  of  the  uterus  will 
often  take  place  and  the  menstrual  flow  cease  at  a  comparatively 
early  age,  to  be  then  followed  by  rapid  development  of  phthisis. 

The  menstrual  changes  in  both  duration  and  quantity  are  more 
gradual  with  the  unmarried.  Of  all  forms  of  flexure,  those  of  the 
cervix  are  borne  the  longest  without  menstrual  disturbance.  But 
long  before  nature  desists  from  her  eff"orts,  or  atrophy  has  commenced, 
fatty  degeneration  will  take  place  at  the  seat  of  flexure.  An  absorp- 
tion of  tissue  is  brought  about  by  pressure  at  this  point,  and  a  perma- 
nent deformity  remains.  The  mechanical  result  is  the  same  as  after 
recovery  from  the  breaking  down  of  the  spongy  portion  of  the  spinal 
column  from  caries,  and  the  curvature  is  likewise  in  proportion  to  the 
loss  of  structure. 


UTERINE    FLEXURES.  351 


CHAPTER    XVIII. 

TREATMENT  OF  FLEXURES  OF  THE  UTERUS. 

Errors  in  pattology — Intra-uterine  stem  pessaries — Dilatation — Curved  tents — 

Division  of  cervix. 

It  must  be  now  evident,  from  what  has  already  been  stated  in 
regard  to  the  supposed  ca\ises  of  flexures,  that  no  course  of  treatment 
can  be  adopted  which  would  be  generally  applicable. 

The  sole  cause  of  confusion  which  has  existed  hitherto  in  regard 
to  the  proper  treatment  originated  in  the  error  of  attempting  to  treat 
the  common  symptom  or  result  as  the  disease.  The  condition  in 
common  was  the  flexure,  under  which  head  have  been  placed  eff'ects 
produced  by  very  different  causes. 

It  has  been  clearly  shown  that  not  only  must  a  wide  distinction  be 
drawn  between  a  flexure  of  the  cervix  and  one  of  the  uterine  body, 
but  also  between  the  different  forms  of  the  latter.  In  one  condition, 
as  has  been  shown,  the  exciting  cause  is  a  want  of  proper  develop- 
ment, with  a  result  which  takes  place  mechanically,  and  produces,  as 
a  rule,  no  disturbance,  except  at  the  beginning  of  the  menstrual 
period.  The  other  condition,  a  flexure  of  the  uterine  body,  is  a  result 
brought  about  by  obstruction  to  the  circulation,  its  site  being  deter- 
mined, as  it  were,  by  accident,  and  it  is  frequently  complicated  by 
inflammation. 

Much  mischief  has  resulted  during  the  past  eighteen  years  from 
the  want  of  accurate  knowledge  as  to  the  true  pathology  of  these 
cases.  Should  the  views  which  are  now  being  presented  prove,  on 
further  investigation,  incorrect,  the  error,  at  least  as  taught,  will 
produce  little  harm.  Since  the  practice  of  indiscriminate  division  of 
the  cervix  was  first  introduced  by  Prof.  Simpson,  more  malpractice 
has  been  perpetuated  throughout  the  world  in  the  name  of  this  simple 
operation,  than  from  any  other  procedure  known  to  the  profession. 
For  years  past,  the  treatment  of  flexures  has  consisted  in  a  resort  to 
surgical  means,  to  the  use  of  the  intra-uterine  stems,  or  to  frequent 
dilatation. 

The  intra-uterine  stem  and  the  practice  of  dilatation  for  the  treat- 
ment of  flexures  might,  with  our  present  views  of  the  pathology,  be 


352      TREATMENT  OF  FLEXURES  OF  THE  UTERUS. 

dismissed  "without  further  comment.  But,  unfortunately,  members  of 
the  profession  are  frequently  advocating  the  use  of  the  stem  pessary, 
regardless  of  the  experience  of  those  who  have  gone  before  them, 
until  they  in  turn  have  to  learn  that  they  have  not  been  the  Aviser  in 
their  day.  As  soon  as  the  true  condition  comes  to  be  appreciated, 
the  use  of  the  intra-uterine  stem  will  be  abandoned  as  a  most  irrational 
instrument.  Experience  will  at  last  teach  every  one  that  no  perma- 
nent benefit  is  ever  derived  from  its  use ;  that  no  degree  of  tolerance 
is  ever  established ;  but  that  sooner  or  later,  in  almost  every  case, 
mischief  will  result.  I  have  long  taught  that  its  use  in  a  flexure 
would  be  as  irrational  as  the  introduction  of  a  straight  steel  sound 
into  the  urethra  for  the  relief  of  an  existing  chordee  ;  the  penis  might 
be  straightened  by  force,  but  the  cause  of  difficulty  would  certainly 
not  be  removed.  "Were  we  to  straighten  out  a  flexure  of  the  cervdx 
by  means  of  an  intra-uterine  stem,  the  end  of  the  instrument  would 
make  continued  pressure  on  the  posterior  wall  of  the  vagina  on 
account  of  the  want  of  necessary  space  in  the  canal.  So  much  dis- 
turbance, in  an  American  woman  at  least,  would  be  excited  in  the 
vagina  and  uterus  that  inflammation  Avould  certainly  become  estab- 
lished if  its  use  were  persevered  in.  Then,  as  soon  as  the  instrument 
is  removed,  the  neck  will  return  to  its  original  condition. 

If  this  instrument  be  employed  with  a  flexure  of  the  uterine  body, 
the  disturbance  is  likely  to  be  even  more  marked.  A  condition  here 
exists  which  so  closely  resembles  an  inflammatory  one,  that  the 
slightest  provocation  is  often  sufficient  to  establish  cellulitis  and, 
even,  general  peritonitis.  "Whenever,  by  sanction  of  a  merciful  Provi- 
dence, the  stem  has  been  tolerated  for  a  time,  even  in  this  condition, 
no  more  progress  will  have  been  made  towards  removing  the  existing 
cause  of  the  flexure  than  would  be  accomplished  by  the  sound  in  a 
case  of  chordee.  Moreover,  Avere  its  use  entirely  successful,  so  far 
that  the  canal  remained  perfectly  straight,  and  patulous  afterwards, 
the  cause  of  the  flexure  Avould  remain,  and  the  pain  of  menstruation 
would,  in  all  probability,  be  increased  in  consequence  of  such  dis- 
turbance. 

The  same  objections  are  to  be  advanced  against  the  practice  of 
dilating  with  either  steel  sounds  or  the  sponge  tent,  so  far  as  they 
may  be  employed  for  the  relief  of  a  flexure  of  the  uterine  body.  The 
use  of  the  curved  sponge  tent,  which  I  was  accustomed  to  employ 
fifteen  years  ago  to  straighten  a  flexure,  produced  less  irritation  than 
the  passage  of  a  number  of  the  steel  dilators  for  the  same  purpose. 


SURGICAL    PROCEDURES.  353 

But  the  use  of  either  is  faulty  in  theory,  and  without  permanent 
benefit,  and  the  practice  is  always  attended  Avith  risk. 

There  are  certain  forms  or  conditions  of  flexure,  in  which  we  must 
resort  to  surgical  means  for  relief,  and  there  are  others  in  which 
it  would  be  malpractice  to  employ  them.  It  may  be  accepted  as  a 
truism,  derived  from  experience,  that,  in  flexure  of  the  uterine  body, 
no  surgical  procedure  will  be  of  the  slightest  use  towards  permanently 
removing  the  conditions  ;  and  that  whenever  practised,  in  the  usual 
conditions,  the  life  of  the  patient  is  thereby  unnecessarily  placed  in 
jeopardy.  The  only  exception  to  the  rule  is,  when  a  flexure  of  the 
body  forward  has  so  long  existed,  that,  from  absorption  of  tissue  at 
the  angle,  the  condition  has  become  a  permanent  deformity.  In  this 
state,  after  the  proper  preparatory  treatment,  as  we  shall  see,  an 
operation  is  sometimes  advisable. 

Quite  difierent  is  the  condition  where  the  flexure  is  below  the 
vaginal  junction.  The  body  of  the  uterus  is  then  found,  as  a  rule,  in 
position  at  a  right  angle  to  a  long  and  pointed  neck  Avhich  presents  in 
the  axis  of  the  vagina.  This  lesion  has  been  attributed  to  a  fault  in 
nutrition,  and  is  one  which  only  by  accident  is  ever  complicated  by 
inflammatory  action.  Both  dysmenorrhoea  and  sterility  exist,  as  a 
rule,  with  this  condition,  but,  as  has  been  already  shown,  with  little 
or  no  uterine  disease  until  at  a  somewhat  advanced  period  of  married 
life.  This  is  one  of  the  commonest  of  the  mechanical  causes  of 
sterility,  and  when  surgical  means  can  be  applied  at  an  early  period, 
the  result  has  proved,  in  my  experience,  very  satisfactory  in  remov- 
ing the  sterility,  and  in  affording  relief  to  the  painful  menstruation. 
But  these  results  are  only  gained,  in  so  satisfactory  a  manner,  in 
simple  uncomplicated  cases  of  flexure  of  the  cervix,  such  as  we  find 
shortly  after  marriage,  in  early  life,  and  before  any  form  of  uterine 
disease  has  supervened.  Yet,  in  only  a  small  percentage  of  flexures 
of  the  cervix  are  we  justified  in  resorting  to  surgical  means.  It  should 
never  be  performed  on  the  unmarried  woman,  except  in  extreme  cases 
of  dysmenorrhoea,  when  the  neck  is  unusually  long.  Yet,  this  is  not 
to  convey  the  impression  that  I  am  in  favor  of  neglecting  the  treatment 
of  an  unmarried  woman  as  such.  A  large  proportion  of  these  cases 
may  become  impregnated  after  marriage,  notwithstanding  the  existence 
of  flexure.  I  do  not,  therefore,  advocate  the  operation  if  it  can  be 
avoided,  and  if  there  should  be  any  prospect  of  marriage.  The  woman 
should  receive  the  same  local  treatment  as  would  be  deemed  applicable 
in  any  case  where  the  degree  of  flexure  was  not  sufficient  to  jusify  an 
operation.  For  the  sterile  women,  the  operation  should  be  performed 
23 


354      TREATMENT  OF  FLEXURES  OF  THE  UTERUS. 

after  a  reasonable  delay,  whenever  the  dysmenorrhoea  is  severe  and  has 
increased  since  marriage,  but  it  will  prove  of  little  value  for  the  relief 
of  sterility  if  it  has  existed  without  painful  menstruation.  Whenever 
the  cervix  is  of  unusual  length,  the  operation  is  necessary  to  remove 
a  condition  which,  from  sexual  intercourse,  is  likely  to  result  in  retro- 
version. With  this  displacement,  prolapse  and  increased  elongation 
of  the  cervix  afterwards  take  place,  as  the  body  of  the  uterus  becomes 
forced  over  into  the  axis  of  the  vagina. 

The  ultimate  result  of  this  operation  is  to  bring  the  neck  of  the 
uterus  to  a  more  natural  length,  and  it  then  becomes  straighter, 
shorter,  and  thicker.  This  change  in  the  neck  is  brought  about,  it  is 
supposed,  by  the  action  of  the  longitudinal  fibres,  after  the  circular 
ones  have  been  divided.  The  course  of  the  muscular  fibres  of  the 
cervix  is  not  so  well  defined  as  in  the  body  of  the  uterus,  being  more 
matted  together ;  consequently,  this  explanation  may  not  be  accepted 
without  question.  But,  of  the  result,  there  can  exist  no  doubt.  We 
will,  therefore,  leave  the  question  to  be  determined  by  others, 
whether  the  result  is  produced  by  contraction  of  the  cicatricial  sur- 
faces of  the  divided  cervix,  opposite  the  flexure,  or  by  muscular  action. 

Sir  James  Y.  Simpson  first  proposed  and  practised  a  lateral  division 
of  the  cervix  for  overcoming  a  narrowing  of  the  canal,  and  for  opening 
the  passage  when  encroached  upon  by  a  flexure.  The  results  of  this 
practice  were  not  entirely  satisfactory,  when,  about  1860,  Dr.  Siras's 
ingenuity  suggested  an  incision  of  the  posterior  lip  backward  in  the 
median  line.  After  a  few  operations  had  been  performed  by  him,  he 
returned  to  the  lateral  method,  and  at  the  time  of  his  leaving  the 
country  in  1862  that  was  his  usual  practice.  While  in  Europe  he 
seemed  to  have  revived  the  original  operation,  and  has  recently  re- 
sorted to  it  more  frequently.  Bvit,  as  far  as  I  have  had  the  opportunity 
of  judging,  my  impression  is  that  the  lateral  operation,  as  a  rule,  is  his 
usual  practice.  Having  had  the  opportunity  of  observing  the  results 
of  his  practice  more  closely  than  he  could  himself,  and  also  by  watch- 
ing my  own,  I  became  satisfied  that  neither  mode  of  operating  will 
relieve  a  flexure  of  the  uterine  body.  As  early  as  1865,  I  placed  on 
record  the  views  I  then  held,  and  had  already  taught  for  several 
years  previous.  These  views  were  nearly  the  same  as  I  hold  to- 
day, both  in  relation  to  the  pathology  and  the  treatment  of  flexures. 
I  then  wrote,^  "  I  am  satisfied  that  neither  operation  will  permanently 

•  "  Treatment  of  Dysmenorrhoca  and  Sterility,  resulting  from  Antoflexure  of  tlio 
Uterus."     New  York  Medical  Journal,  June,  1805. 


SURGICAL    PROCEDURES.  355 

relieve  any  case,  unless  the  flexure  is  confined  to  the  neck,  and  is 
below  the  vaginal  junction.  While  the  backward  operation,  as  pro- 
posed, would  relieve  a  moderate  flexure,  the  lateral  one,  even  if  ex- 
tended on  each  side  to  the  vaginal  junction,  could  not  accomplish  so 
much,  unless  the  posterior  flap  in  the  process  of  healing  retracted 
sufficiently  to  clear  the  seat  of  stricture,  which  it  could  not  do.  The 
dysmenorrhoea  invariably  returns  after  a  few  months,  so  soon  as  the 
more  revulsive  effects  of  the  operation  have  subsided."  My  views  at 
that  time  were  that  a  much  larger  proportion  of  flexures  needed  the 
operation,  but  more  especially  for  the  purpose  of  facilitating  the 
application  of  after  treatment  to  the  canal.  The  additional  experi- 
ence of  twelve  or  thirteen  years  has  only  confirmed  my  views  the 
more  in  limiting  the  operation  to  a  flexure  of  the  cervix,  with  the 
single  exception  which  has  been  cited. 

Were  other  advantages  equal,  the  backward  operation  is  preferable 
to  the  lateral  one,  since  the  cervix  is  divided  only  in  one  direction,  and 
the  risk  from  hemorrhage  is  less,  as  the  circular  artery  can  be  easily 
avoided.  Moreover,  there  will  be  no  gaping  or  rolling  out  of  the 
edges  after  they  have  healed,  as  the  flaps  will  be  kept  sufficiently  in 
contact  by  the  lateral  walls  of  the  vagina.  When  we  come  to  consider 
the  effect  of  laceration  of  the  cervix  which  occurs  at  childbirth,  the 
bearing  of  this  circumstance  in  relation  to  the  eversion  of  the  flaps 
will  be  better  appreciated.  Another  objection,  and  in  fact  the  most 
important  one,  to  be  urged  against  the  lateral  operation,  is  the  greater 
liability  to  the  occurrence  of  cejlulitis  after  it.  In  the  lateral  opera- 
tion the  cervix  is  divided  on  both  sides,  consequently  it  might  be 
justly  claimed  that  the  risk  Avas  at  least  twice  as  great  as  when  it  is 
simply  incised  backwards.  But  the  danger  from  the  lateral  operation 
is  still  further  greatly  enhanced  by  the  fact  that,  when  the  cervix  is 
divided  laterally  to  the  vaginal  junction,  the  incisions  go  down  to, 
and  frequently  into,  the  cellular  tissue  of  the  pelvis  inclosed  on  each 
side  between  the  folds  of  the  broad  ligament.  These  incisions  are 
thus  made  in  close  proximity  to  immense  plexuses  of  veins  and  venous 
sinuses  in  the  uterus  itself,  which  are  more  numerous  nearer  to  the 
lateral  surfaces,  so  that  these  may  become  readily  involved  by  any 
local  inflammation.  In  the  backward  operation,  it  is  never  well  to 
extend  the  incision  to  the  vaginal  junction,  although  there  really  exists 
but  little  cellular  tissue  in  this  neighborhood  likely  to  become  involved. 

The  operation  is  now  generally  performed  with  either  the  knife  or 
scissors.  Simpson's  uterotome  Avas  first  employed,  but  there  were  so 
many  objections  to  it  that  Dr.  Sims  devised  an  instrument  for  the 


356  TREATMENT    OF    FLEXURES    OF    THE    UTERUS. 

purpose  having  a  narrow  cimeter-shaped  blade  which,  with  my  modi- 
fication, has  been  described  in  the  chapter  on  Instruments,  page  43. 
Early  in  I860, 1  had  the  scissors,  of  which  a  cut  is  given  on  page  41, 
made  for  this  operation.  These  scissors  were  the  first  used  for  this 
operation,  and  are  of  interest  from  being  the  first  of  the  various  forms 
now  in  general  use.  Their  introduction  was  of  no  little  importance, 
since  they  gave  an  impulse  to  this  branch  of  surgery  and  have 
afibrded  a  facility  for  performing  many  operations  in  which  the  knife 
is  of  little  value. 

In  the  article  just  quoted  from  (written  in  1865),  I  stated  "  I  have 
for  several  years  in  this,  as  in  all  other  operations  of  obstetrical  surgery, 
substituted,  as  far  as  possible,  the  use  of  the  scissors  for  the  knife. 

"  The  scissors  that  I  have  been  in  the  habit  of  using  for  this  opera- 
tion are  fiat  on  the  face,  but  have  the  blades  bent  at  an  angle  from  the 
handles,  so  as  to  conform  somewhat  to  the  direction  of  the  uterine 
canal."  I  prefer  the  scissors  for  the  operation,  since,  in  addition  to 
the  loss  of  blood  being  less,  I  am  certain  that  the  risk  from  blood- 
poisoning  is  not  so  great  after  the  parts  have  been  crushed  apart  by  a 
pair  of  scissors,  as  when  separated  by  a  clean  cut.  The  process  of 
healing  is  also  comparatively  less  rapid  after  the  use  of  the  scissors. 

The  proper  time  for  performing  the  operation  is  within  a  few  days 
after  the  cessation  of  the  menstrual  period,  but  should  not  be  under- 
taken so  long  as  the  slightest  tenderness  can  be  detected  in  the  vagina 
on  pressure  of  the  finger.  An  excellent  feature  in  the  preparatory 
treatment  is  the  administration,  once  or  twice  a  day,  of  a  large  hot 
water  vaginal  injection.  As  an  essential,  before  every  operative  pro- 
cedure, it  is  necessary  that  the  bowels  should  have  been  emptied 
within  a  feAV  hours  of  the  operation.  After  preparing  a  proper  table 
for  the  operation,  the  patient  is  to  be  placed  on  the  left  side,  and  her 
body,  as  well  as  her  limbs,  protected  from  exposure  to  cold.  After 
introducing  the  speculum,  by  seizing  the  anterior  lip  of  the  uterus,  and 
drawing  it  gently  forward,  a  series  of  small  radiating  folds  are  gener- 
ally formed  and  can  be  noticed  passing  backward  from  the  vaginal 
junction  at  the  bottom  of  the  cul-de-sac.  The  starting  point  of  these 
folds  is  along  the  vaginal  junction,  and  they  are  to  be  the  guide  in 
limiting  the  incision  through  the  posterior  lip,  so  as  not  to  Avound  the 
circular  artery. '  "While  the  cervix  is  being  steadied  by  means  of  the 
tenaculum,  a  probe  is  introduced  to  the  fundus,  as  a  guide  before 
making  the  incision.  The  tenaculum  and  the  probe  can  then  be  held 
in  one  hand,  and  with  the  other  the  division  is  to  be  made.  One  limb 
of  the  scissors  is  to  be  introduced  within  the  uterine  canal,  alongside 


BACKWATID    INCISION. 


357 


of  the  probe,  to  a  sufficient  depth  to  extend  the  incision  through  the 
posterior  lip,  stopping  just  short  of  the  vaginal  junction,  the  point  from 
which  the  folds  radiate,  as  has  been  described.  It  will  be  seen  by  a 
glance  at  Fig.  56,  that  the  blades  of  the  scissors  must  necessarily 
move  in  an  arc  of  a  circle  along  the  line  A  B,  by  which  a  triangular 
portion  Avill  remain.  For  its  removal,  I  use  the  ball  and  socket  knife 
(see  page  43),  by  passing  the  blade,  with  its  cutting  edge  backward, 
along   the    probe   as  a  guide,  into  the  canal  beyond  the  point  C, 

Figf.  56. 


Liaes  of  incisions  in  flexure  of  the  cervix. 


and  the  triangular  portion  is  divided  along  the  line  C  A,  as  the  in- 
strument is  being  withdrawn.  The  probe  can  then  be  removed,  and, 
by  the  passage  of  an  ordinary  uterine  sound,  the  extent  to  which  the 
canal  has  already  been  opened  can  be  ascertained,  and  the  necessity 
for  extending  the  incision  can  also  be  judged  of  by  the  same  means. 
After  a  few  moments'  delay,  to  ascertain  the  extent  of  bleeding,  the 
vagina  can  be  packed  with  some  substance  to  form  a  tampon,  as  a 
protection  against  further  loss  of  blood.  We  may  use  for  the  tampon 
either  damp  cotton,  which  has  been  saturated  with  a  solution  of  alum, 
and  afterwards  squeezed  nearly  dry,  or  a  fine  quality  of  oakum.     After 


358      TREATMENT  OF  FLEXUEES  OF  THE  UTERUS. 

an  operation  of  this  kind  the  oakum  is  preferable,  if  the  best  quality 
can  be  obtained.  It  has  in  itself  disinfecting  properties,  and  "when 
properly  introduced  does  not  shrink  in  bulk,  as  the  cotton  tampon 
always  does  after  a  few  hours.  In  a  previous  chapter,  the  use  and 
mode  of  introducing  the  tampon  are  fully  treated  of,  and  it  becomes, 
therefore,  unnecessary  to  repeat  these  directions.  Before  introducing 
the  tampon,  a  portion  of  cotton,  saturated  with  glycerine,  should  be 
passed,  by  means  of  the  applicator,  well  into  the  cervical  canal,  and 
be  allowed  to  remain  packed  between  the  cut  surfaces  until  loosened 
by  commencing  suppuration.  The  vagina  should  be  well  filled  by  the 
tampon,  as  if  a  hemorrhage  actually  existed  at  the  time,  since  the 
only  safeguard  against  the  dangers  of  hemorrhage  is  to  prevent  its 
occurrence.  It  is  far  easier  to  prevent  a  hemorrhage  than  to  arrest  it 
after  it  has  once  begun.  It  is  a  peculiarity  of  vessels  situated  in 
loose  cellular  or  erectile  tissue,  that,  Avhen  cut  across,  their  orifices 
become  rapidly  dilated  from  the  rotatory  force  created  by  the  current 
in  its  escape. 

It  is  a  fact  well  known  in  hydraulics,  that  the  amount  of  fluid 
which  can  escape  from  a  pipe,  in  a  given  time,  will  vary  according  to 
the  shape  of  the  orifice.  When  the  orifice  is  trumpet  shaped,  like  the 
dilated  vessels,  the  escape  of  fluid  in  a  given  time  will  be  many-fold 
greater  than  that  which  would  issue  from  an  opening  made  only  equal 
in  calibre  to  the  diameter  of  the  pipe  itself.  Therefore,  the  quantity 
of  blood  which  will  escape  from  one  of  these  vessels  will  be  in  pro- 
portion to  the  length  of  time  the  flow  is  allowed  to  continue.  I  have 
frequently  noticed  the  mouth  of  a  divided  vessel  in  this  tissue  increase 
rapidly  in  size  from  a  mere  point  to  an  orifice  sufficiently  large  to 
admit  the  extremity  of  a  probe.  The  occurrence  of  hemorrhage 
should,  therefore,  be  guarded  against,  not  only  for  the  exhaustion  it 
induces,  but  because  it  also  renders  the  patient  more  liable  to  inflam- 
mation. This  may  take  place  not  only  from  the  greater  volume  of 
blood  which  would  naturally  flow  to  the  parts,  but  in  consequence  of 
the  exposure  to  which  the  patient  must  be  subjected  in  the  attempt  at 
arresting  the  hemorrhage.  Frequently,  the  bleeding  at  the  time  of 
the  operation  is  sufficient  to  make  the  use  of  a  large  tampon  necessary 
as  a  precautionary  measure.  Tliis  will  often  excite  irritation  from 
the  pressure  produced  at  the  neck  of  the  bladder,  and  if  not  relieved, 
will  cause'  much  suffering  to  the  patient.  To  guard  against  this,  a 
suppository  of  morphine  and  belladonna  may  be  introduced  into  the 
rectum,  immediately  after  completing  the  operation,  or  an  enema  of 
some  preparation  of  opium  may  be  used  for  the  same  purpose.     After 


TREATMENT    AFTER    INCISION    OF    THE    CERVIX.  359 

the  lapse  of  a  few  hours,  a  portion  of  the  tampon,  from  the  immediate 
nei<^hborhoo(l  of  the  neck  of  the  bladder,  may  be  removed  if  there  is 
no  indication  of  hemorrhage  at  the  time,  and  this  will  be  made  evi- 
dent by  the  appearance  of  the  cotton  at  the  vaginal  outlet.  To  enable 
the  operator  to  remove  the  cotton  with  safety,  it  is  necessary  that  the 
patient  should  make  no  exertion.  Her  shoulders  should  be  shifted  to 
the  middle  of  the  bed  by  drawing  on  her  pillow,  so  that  her  body  will 
lie  across  the  bed  with  her  limbs  drawn  up,  and  her  hips  resting  near 
the  edge.  The  index  finger,  as  a  guide,  can  be  gently  introduced 
into  the  vagina  without  exposure  of  the  patient,  and  alongside  of  it 
can  be  passed  the  forceps,  or  the  notched  whalebone  stick.  By 
twisting  the  end  of  the  stick  into  one  piece  of  cotton  after  another,  a 
sufficient  quantity  can  be  removed  to  give  entire  relief.  But  unless 
this  necessity  exists,  the  patient  should  not  be  disturbed  until  the 
second  day  after  the  operation,  when  the  tampon  must  be  carefully 
withdrawn  and  renewed.  ■  To  do  this  properly,  it  will  be  necessary 
to  place  the  patient  on  the  table,  and  to  make  use  of  a  speculum.  The 
tampon  is  to  be  i-emoved  piece  by  piece  until  the  cervix  becomes  ex- 
posed, but,  to  avoid  causing  hemorrhage,  the  plug  between  the  sides 
of  the  wound  should  remain  undisturbed  until  the  third  or  fourth  day, 
when  it  will  become  loosened  by  suppuration.  Before  replacing  the 
tampon,  I  make  it  a  rule  to  swab  out  the  vagina  with  hot  water  as 
thoroughly  as  can  be  done,  by  means  of  a  large  piece  of  sponge  held 
in  the  grasp  of  a  probang,  or  a  pair  of  forceps.  Then  over  the  cervix 
is  to  be  placed  some  cotton  saturated  with  glycerine,  to  which  should  be 
added  a  few  drops  of  impure  carbolic  acid,  and  afterwards  the  tampon. 
As  soon  as  the  plug  can  be  removed  readily ,  and  the  wound  begins 
to  discharge,  the  granulating  surfaces  may  be  cleansed  by  carefully 
throwing  in  a  little  warm  water  by  means  of  a  syringe.  A  fresh  plug 
of  cotton,  saturated  with  glycerine,  should  be  introduced  daily  be- 
tween the  edges  of  the  wound,  but,  before  doing  so,  the  sound  must 
be  passed  with  care  into  the  uterine  canal,  so  that,  as  it  is  being 
removed,  its  point  may  be  drawn  with  sufficient  pressure  along  the 
angle  of  the  wound  to  keep  it  from  uniting  too  rapidly.  For  the  first 
five  or  six  days,  but  little  more  will  be  needed  than  to  break  up  the 
healing  in  the  angle  just  at  the  vaginal  surface,  for  at  this  point,  the 
union  will  first  begin,  and  contraction  rapidly  follow.  The  tampon  may 
be  lessened  in  size  after  the  second  removal,  according  to  the  existing 
tendency  to  hemorrhage,  and  after  the  tenth  day  may,  as  a  rule,  be 
discontinued.  But  it  will  be  then  necessary  to  resume  the  vaginal 
injections  in  the  morning,  w^ith  a  glycerine  dressing  afterwards. 


360      TREATMENT  OF  FLEXURES  OF  THE  UTERUS. 

The  patient  cannot  be  watched  with  too  much  care,  to  guard  her 
against  exposure  to  cold  and  consequent  inflammation,  which  is  almost 
always  brought  on  by  some  imprudence  on  her  part.  For  the  subse- 
quent examination,  she  should  be  protected  by  stockings  and  drawers, 
and  be  lifted  from  the  table  to  her  bed  while  wrapped  in  a  blanket 
which  is  to  cover  her  from  the  shoulders  to  the  feet.  When  neces- 
sary, she  must  use  the  bed-pan  in  the  recumbent  position,  if  possible, 
but  if  she  be  so  unfortunate  as  to  be  unable  to  empty  the  bladder 
while  in  this  position,  the  catheter  must  be  used  during  the  first  week. 
As  a  rule,  it  is  not  safe  for  a  patient  to  sit  up  until  at  least  ten  days 
after  the  operation,  and  even  then,  if  any  tenderness  can  be  detected 
by  pressure  of  the  finger  in  the  vagina,  she  should  remain  in  bed 
until  the  danger  has  passed.  I  do  not  consider  a  patient  safe  from  ' 
the  dangerous  effects  of  this  operation  until  after  the  next  menstrual 
period.  Although,  as  a  rule,  I  permit  a  patient  to  sit  up  after  the 
tenth  day,  I  insist  on  the  greatest  care  being  observed  that  she  shall 
not  remain  up  long  enough  to  suffer  from  fatigue,  until  all  danger  has 
passed.  Moreover,  experience  has  taught  that  it  is  necessary  for  the 
patient  to  remain  in  bed  during  the  subsequent  menstrual  period,  and 
the  rule  should  be  observed  notwithstanding  there  be  apparently  no 
occasion  for  this  precaution.  Menstruation  always  returns  before  the 
parts  have  become  thoroughly  healed,  while  the  pelvic  vessels  are 
still  overcharged,  in  consequence  of  the  irritation  following  upon  the 
operation,  and  as  an  accompaniment  of  the  reparative  process.  There- 
fore, the  serious  features  of  the  condition  are  not  exaggerated.  Tlie 
danger  to  life  is  not  so  great  as  it  would  have  been  within  a  shorter 
time  after  the  operation,  but  without  care  during  this  menstrual  period, 
the  risk  of  some  additional  complication  is  certainly  very  great,  where- 
by the  condition  of  the  woman  would  be  made  infinitely  worse  than  it 
was  previous  to  the  operation.  Much  of  the  disappointment  attending 
the  unsatisfactory  results  which  have  followed  this  operation  can  be 
attributed  to  the  want  of  an  appreciation  of  the  necessity  for  main- 
taining the  recumbent  position  at  this  time.  I  am  certain  there  will 
be  very  few  of  my  readers,  after  any  experience  in  this  operation, 
who  will  not  be  able  now  to  recall  many  instances  of  unexpected  com- 
plications coming  on  after  the  menstrual  period.  The  uterus  will  be 
found  suddenly  enlarged,  or  thickening  will  be  detected  between  the 
folds  of  one  or  both  of  the  broad  ligaments,  or  even  the  existence  of 
an  hematocele  will  be  recognized  for  the  first  time  after  the  menstrual 
period  has  ceased,  although,  before  the  flow  came  on,  there  may  have 
existed  no  indication  of  any  complication.     The  most  frequent  com- 


DANGER    OF    FORWARD    INCISION.  361 

plication  is  the  sudden  enlargement,  or  congestive  hypertrophy,  of  the 
uterus,  which  will  suddenly  come  on,  or  be  detected  after  the  patient 
has  been  supposed  to  be  convalescent.  She  may  not  have  been  spe- 
cially imprudent,  yet  no  particular  care  probably  Avas  taken  during 
the  menstrual  period  just  passed,  as  hitherto  the  relation  of  cause 
and  effect  has  not  been  recognized. 

We  have  seen  that  a  long  cervix  is  sometimes  the  cause  of  retro- 
version, a  position  which  results  in  flexure  as  the  fundus  of  the  uterus 
settles  lower  into  the  hollow  of  the  sacrum,  and  the  neck  becomes 
pressed  upward  against  the  anterior  Avail  of  the  vagina.  Formerly, 
I  divided  the  anterior  lip  upward  in  the  median  line,  for  the  relief  of 
the  dysmenorrhoea  which  always  accompanies  this  form  of  flexure  of 
the  cervix.  But  experience  at  length  taught  me  that  no  relief  can  be 
obtained  by  any  surgical  means,  so  long  as  the  body  of  the  uterus 
remains  retroverted,  and  that  any  operation  of  the  kind  is  always 
attended  with  great  danger.  Whenever  the  fundus  becomes  so  much 
displaced  backwards  as  to  cause  a  flexure  in  either  the  body  or  the 
cervix,  inflammation  will  have  long  before  been  excited  in  the  neigh- 
boring cellular  tissue  as  a  consequence  of  the  malposition.  So  long 
as  the  displacement  of  the  uterus  exists,  an  irritable  condition  will 
remain  afterwards  latent,  which  will  require  much  less  provocation 
than  a  division  of  the  cervix  to  establish  the  inflammation  in  full  force. 
To  my  sorrrow,  I  have  had  pelvic  cellulitis  with  abscesses  frecj[uently 
occur,  and  death  in  one  instance,  after  the  most  careful  preparatory 
treatment  previous  to  dividing  the  cervix  of  a  retroflexed  uterus, 
when,  at  the  time,  there  was  not  the  slightest  indication  of  danger. 
In  fact,  I  am  unable  to  recall  a  single  instance  where  inflammatory 
symptoms  did  not  occur,  if  an  attempt  was  persevered  in  to  keep  open 
the  incision  while  the  uterus  remained  in  this  position.  The  uterus 
must  be  gotten  into  a  favorable  position  or  anteverted  by  a  pessary, 
as  shown  in  Fig.  54,  when,  if  the  cervix  is  too  long,  it  may  become 
flexed  in  the  opposite  direction.  Then,  if  necessary,  after  the  proper 
preparatory  treatment,  the  cervix  may  be  divided  backward. 

In  the  treatment  of  flexures  of  the  uterine  body,  Ave  are  to  be 
guided  by  the  same  general  principles  as  would  be  applicable  to  the 
treatment  of  disease  of  uterine  condition  without  the  accident  of 
flexure.  We  may,  hoAvever,  accept  the  presence  of  the  flexure  as 
conclusive  evidence  that  the  most  careful  general  treatment  will  be 
necessary,  and  without  it  the  local  means  to  be  employed  will  prove 
of  little  value.  Just  in  proportion  to  any  improvement  Avhich  can  be 
brought  about  in  the  general  condition  to  influence  and  give  tone  to 


362      TREATMENT  OF  FLEXURES  OP  THE  UTERUS. 

the  pelvic  vessels,  will  the  degree  of  flexure  be  lessened.  The  chief 
local  means  to  he  employed  for  giving  tone  to  the  vessels  and  removing 
the  chronic  state  of  venous  stagnation  Avill  lie  in  the  proper  use  of  the 
hot-water  vaginal  injections.  The  frequent  use  of  iodine  will  be  of 
service  when  applied  throughout  the  canal  by  means  of  the  applicator, 
after  this  has  been  bent  to  the  proper  curve,  corresponding  to  the 
degree  of  flexure,  as  ascertained  by  the  use  of  the  probe.  When  the 
uterus  is  enlarged,  and  the  cervix  hard,  a  blister  of  the  acetic  solution 
of  cantharides  applied  to  the  neck,  shortly  after  each  period,  will  be 
of  service.  This  agent  will  relieve  the  local  congestion  by  the  watery 
discharge  it  produces  ;  the  revulsive  effect  will  prove  beneficial  also, 
and  the  remedy  is  further  valuable  in  exciting  uterine  contractions. 
The  daily  use  of  glj^cerine,  to  be  applied  in  the  vagina  by  saturating 
with  it  a  sufficient  quantity  of  cotton,  will  prove  indispensable.  When- 
ever the  stomach  will  tolerate  the  use  of  small  doses  of  ergot  in  some 
form,  the  remedy  should  be  given  in  conjunction  with  tonics,  since 
its  eflect  on  the  pelvic  and  uterine  circulation  will  prove  most  bene- 
ficial. But  to  obtain  the  wished-for  result  from  this  agent,  its  use 
must  be  long  continued,  and  in  such  doses  as  not  to  cause  any  dis- 
turbance of  the  stomach  or  marked  uterine  pains,  since  the  latter 
would  establish  a  condition  calculated  to  increase  the  deo;ree  of 
flexure. 

It  has  already  been  stated  that,  in  consequence  of  long-continued 
pressure  at  the  angle  of  flexure,  absorption  of  tissue  gradually  takes 
place,  leaving  a  condition  of  permanent  deformity.  With  this  condi- 
tion existing,  and  with  the  disappearance  of  all  evidence  of  cellulitis, 
it  is  the  proper  treatment  to  open  the  passage  sufficiently  that  the 
flexure  may  no  longer  produce  dysmenorrhoea,  or,  by  retention  of  the 
secretions  within  the  canal,  maintain  an  exciting  cause  for  future 
disease  and  relapse.  Fig.  57  is  intended  to  illustrate  a  flexure  of 
the  body  above  the  vaginal  junction,  which  has  remained  unchanged 
after  the  proper  treatment.  For  the  operation,  the  same  directions 
are  applicable  as  have  already  been  given.  The  posterior  lip  is  to 
be  divided  backward  by  scissors  along  the  probe,  in  the  canal  as  a 
guide,  in  the  median  line  to  BD,  and  then  the  triangular  por- 
tion ABD  is  to  be  incised  by  means  of  the  ball-and-socket  knife. 
The  blade  of  the  knife  is  then  to  be  reversed,  with  its  cutting  edge 
towards  the  operator.  The  uterus  must  be  steadied  with  a  tenaculum 
held  in  the  same  hand  with  the  probe,  which  had  been  previously 
introduced  to  the  fundus  to  serve  as  a  guide.  The  blade  of  the  knife 
can  then  be  passed  alongside  of  the  probe,  when  it  will  divide  rather 


RESULTS    OF    INCISION.  363 

more  than  its  width,  as  shown  by  the  line  DC,  and  this  will  complete 
the  operation.  The  after  treatment  is  to  be  essentially  the  same  as 
that  already  described  for  division  of  the  cervix.  This  operation, 
when  performed  at  the  proper  time  and  under  the  proper  circum- 


Lines  of  incisions  in  flexure  of  the  body. 

stances,  is  often  followed  by  very  satisfactory  results.  Yet  in  my 
experience  it  has  often  failed,  and  there  has  been  a  gradual  return 
to  the  previous  condition,  and  sometimes  the  contraction  has  been 
even  greater  than  existed  before  the  operation. 

During  the  period  from  Sept.  1,  1862,  to  May  1,  1872,  while  I 
held  the  position  of  Surgeon-in-Chief  to  the  Woman's  Hospital,  there 
were  eighteen  hundred  and  forty-two  patients  treated  in  the  institution 
under  my  charge.  Of  this  number,  the  cervix  was  divided  fifty-six 
times  for  flexure.  There  were  three  cases  of  serious  cellulitis  follow- 
ing these  operations,  but  complete  recovery  took  place  in  each  in- 
stance, and  without  the  formation  of  pelvic  abscesses.  Two  deaths 
occurred  as  the  result  of  general  peritonitis,  brought  on  after  these 
patients  were  well  enough  to  be  up,  caused  by  their  own  imprudence 
just  as  the  first  menstrual  period  after  the  operation  was  coming  on. 
One  of  these  patients  was  sent  to  the  hospital  by  Dr.  Bauer  of 
Brooklyn,  but  now  of  St.  Louis.  After  she  had  been  up  for  several 
days,  she  asked  permission  to  take  a  bath,  which  was  refused,  and  she 
was  reminded  that  her  menstrual  flow  would  soon  be  due.  Notwith- 
standing this  caution,  she  took  a  cold  sponge  bath  with  her  window 
open,  on  a  mild  day,  as  it  happened,  although  in  the  middle  of  winter. 


364      TREATMEXT  OF  FLEXURES  OF  THE  UTERUS. 

She  was  seized  with  a  chill  before  she  had  completed  her  toilet, 
and  this  was  followed  by  a  violent  attack  of  peritonitis,  of  which  she 
died  in  a  few  days.  The  other  case,  I  had  operated  on  just  before  the 
change  in  the  organization  of  the  Woman's  Hospital,  in  May,  1872, 
and,  after  a  few  days,  she  passed  from  my  service.  She  continued 
to  do  well  until  three  weeks  after  the  operation,  when  on  going  out 
for  the  first  time,  she  imprudently  indulged  in  too  long  a  drive,  was 
taken  sick  before  her  return,  and  died  within  a  few  days  from  general 
peritonitis. 

From  the  autumn  of  1862  until  the  same  season  in  1875,  when  I 
began  to  arrange  the  statistical  material  which  has  been  used  in  this 
work,  I  had  treated  two  thousand  and  thirty-six  cases  in  my  private 
hospital.  Of  this  number,  there  had  been  forty-nine  cases  of  flexure 
where  the  cervix  had  been  divided,  and  from  which  one  death  had 
occurred.  The  cause  of  death  was  general  peritonitis  coming  on  in 
a  case  where  I  imprudently  performed  the  operation  on  the  day 
after  her  arrival  from  a  long  and  fatiguing  journey — to  oblige  her 
physician,  who  insisted  on  returning  home  without  delay.  In  this  in- 
stance, the  patient  did  well  for  a  week,  when  the  menstrual  flow  came 
on,  I  believe,  at  the  regular  time,  but  she  had,  through  ignorance,  or 
with  the  view  of  avoiding  the  delay,  misrepresented  the  fact.  Having 
had  the  good  fortune,  in  early  life,  to  witness  the  results  in  the  prac- 
tice of  others,  I  made  it  a  rule  never  to  perform  this  operation  outside 
of  either  the  public  or  private  hospital.  I  felt  that  by  this  plan  alone 
would  a  patient  be  kept  sufficiently  under  control  to  protect  her  from 
her  own  impinident  acts.  Consequently,  I  have  never  operated  but 
twice  outside,  and  both  cases  remained  afterwards  under  the  charge 
of  their  physicians.  One  of  these  ladies  suffered  from  a  retroflexion  ; 
she  was  a  foreigner  with  whom  I  was  unable  to  hold  any  personal 
conversation.  The  operation  was  performed  in  a  large  hotel,  where 
she  could  not  get  the  proper  care,  and  she  suffered,  I  have  no  doubt, 
from  exposure.  The  consequence  was  an  attack  of  cellulitis,  which 
terminated  in  a  pelvic  abscess,  from  which  she  died  after  many  months 
of  suffering. 

Formerly,  cellulitis  after  this  operation  was  not  an  infrequent 
occurrence  in  my  private  hospital,  and  I  have  had  several  instances  of 
pelvic  abscess  occur,  from  which,  however,  recovery  finally  took  place. 
But,  for  years  past,  I  have  had  no  difficulty,  since  I  have  appre- 
ciated the  necessity  for  carrying  out  in  detail  the  precautions  which 
I  have  endeavored  to  impress  upon  the  reader. 

When  the  uterus  has  become  retroflexed,  the  fundus  must  be  gotten 


GENERAL    MEASURES.  365 

out  from  the  hollow  of  the  sacrum  as  soon  as  possible.  But  frequently 
the  uterus  is  found  bound  down  by  adhesions,  or  in  too  tender  a  con- 
dition to  be  moved  with  safety.  We  must,  as  in  the  treatment  of 
other  flexures,  resort  to  the  continued  use  of  hot  water  injections,  hot 
baths,  blistering  the  cervix  occasionally,  daily  glycerine  dressings, 
with  the  most  careful  attention  to  the  state  of  the  bowels  and  the 
general  health.  By  degrees,  as  the  tenderness  on  pressure  sub- 
sides, the  fundus  should  be  lifted  day  after  day,  as  far  as  prudent, 
and  without  attempting  too  much  at  any  one  time.  I  have  succeeded, 
after  months  of  careful  daily  manipulation,  in  restoring  the  uterus  to 
its  normal  position,  with  the  gradual  disappearance  of  a  marked 
flexure,  when,  in  the  beginning,  the  organ  was  apparently  bound  down 
bv  adhesions. 


366     PROCIDEXTIA,  OR  PROLAPSE  OF  THE  UTERUS. 


CHAPTER  XIX. 

PROCIDENTIA,  OR  PROLAPSE  OF  THE  UTERUS. 

Causes — Etiology  ;  Table  XXXI.,  sho-n"ing  the  relation  of  procidentia  to  age,  preg- 
nancy, injury,  labor,  and  other  conditions — Treatment,  pessaries,  surgical 
measures — Cystocele — Rectocele . 

This  condition  may  exist  in  every  degree  of  displacement,  from  a 
simple  sagging  of  the  organ  to  the  final  escape  of  the  uterus  from  the 
vagina.  By  general  nse,  the  term  procidentia  is  applied  more  to  the 
condition  of  prolapse  where  some  portion  of  the  organ  has  already 
passed  the  labia.  Prolapse  of  the  posterior,  or  recto-vaginal  septum, 
constitutes  what  is  termed  a  rectocele,  and  the  same  condition  of  the 
anterior  one,  or  the  vesico-vaginal  wall,  forms  a  cystocele.  In  practice, 
procidentia  and  prolapse  have  been  generally  regarded  as  two  distinct 
lesions.  I  shall,  however,  treat  of  the  subject  as  a  displacement  of 
the  uterus,  where  each  of  these  conditions  will  be  regarded  as  only 
steps  in  a  process  which  may  terminate  in  the  final  escape  of  the 
uterus  from  the  vaginal  outlet. 

The  immediate  causes  of  prolapse  are  threefold,  either  some  growth 
above  the  uterus  crowds  it  downward,  or  there  is  an  increase  of 
weight  in  the  organ  itself,  or  there  is  a  want  of  proper  support  below. 
The  first  step  in  the  process  is  usually  to  be  traced  directly  to  the 
absence  of  support  for  the  vaginal  walls  at  the  outlet  of  the  passage, 
from  which  a  further  prolapse  is  soon  induced  by  the  increase  in 
weight  of  the  organ  resulting  from  its  mal-position.  To  whatever 
cause  the  increase  in  size  and  Aveight  of  the  uterus  may  be  due,  the 
organ  will  settle  into  the  pelvis  just  in  proportion  to  the  additional 
burden. 

Complete  procidentia  is  essentially  a  condition  of  middle  life  or  old 
age,  and  occurs  usually  in  those  who  have  given  birth  to  more  than 
the  usual  number  of  children.  But  I  have  seen  it  occur  in  young 
unmarried  women,  in  consequence  of  tenesmus  excited  by  dysentery, 
or  from  lifting,  by  Avhich  the  uterus  became  at  first  retroverted.  I 
have  also  met  with  several  instances  in  which  the  displacement  was 
caused  by  the  disturbance  excited  from  uterine  contraction,  in  the 
attempt  of  the   organ  to  drive   out  a  pedunculated  fibrous  polypus. 


DIFFERENT    STAGES.  367 

In  these  cases,  the  procidentia  remained  complete  after  the  expulsion 
of  the  polyp,  and  after  it  had  sloughed  away. 

Laceration  of  the  perineum,  or  a  patulous  state  of  the  vulva,  must 
take  place  in  every  instance  before  the  procidentia  can  become  com- 
plete. If  the  pressure  from  above  is  sufficient  to  crowd  the  retro- 
verted  uterus  down  against  the  perineum,  it  will  become  gradually 
distended,  and  the  neighboring  tissues  so  thinned  out  from  absorption, 
that  the  proper  resistance  can  no  longer  be  exerted. 

In  practice,  we  will  have  to  deal  with  the  effects  of  childbirth  as 
the  most  common  of  all  causes  in  producing  procidentia,  and  in  all 
these  cases  the  perineum  will  be  found  extensively  lacerated.  Under 
certain  circumstances,  the  neck  of  the  uterus  becomes  lacerated,  and 
whenever  this  accident  occurs,  it  will  always  keep  up  a  sufficient  irri- 
tation to  arrest  the  involution,  or  natural  decrease  in  the  size,  of  the 
organ  after  childbirth.  The  uterus  in  this  condition,  from  its  weight, 
rests  on  the  floor  of  the  pelvis,  and  acting  then  as  a  wedge  to  keep 
the  vagina  dilated,  the  cervix  will  soon  present  at  the  vaginal  outlet. 
Frequently,  the  same  cause,  producing  laceration  of  the  neck  of  the 
uterus,  will  also  split  the  perineum,  and  when  this  accident  has  oc- 
curred to  an  unusual  degree,  so  little  resistance  can  be  offered  to  the 
uterus  that  the  procidentia  may  soon  become  complete.  From  a  Avant 
of  support  below,  the  recto-vaginal  wall  naturally  prolapses  and  forms 
a  rectocele.  Along  the  sulcus,  on  each  side,  the  walls  of  the  vagina 
are  attached  to  the  connective  tissue  and  fasciae  of  the  pelvis,  from 
which  the  canal  receives  much  support.  As  fold  after  fold  of  the 
posterior  wall  of  the  vagina  becomes  prolapsed,  the  connective  tissue 
of  the  pelvis  will,  in  turn,  stretch  sufficiently  to  throw  the  weight  on  a 
portion  beyond,  until,  at  length,  the  uterus  is  reached,  and  as  soon  as 
the  utero-sacral  ligaments  have  been  stretched  sufficiently,  the  uterus 
becomes  retroverted.  As  the  organ  then  settles  towards  the  vaginal 
outlet,  the  anterior  wall  of  the  canal  prolapses  from  behind  forward, 
thus  forming  a  cystocele.  The  tissue  just  posterior  to  the  neck  of 
the  bladder  will  then  be  the  last  to  escape  as  the  procidentia  becomes 
complete. 

When  laceration  of  the  perineum  occurs,  and  the  enlarged  uterus 
happens  to  be  left  anteverted,  the  cervix  will  settle  on  the  floor  of  the 
pelvis  with  the  fundus  behind  the  symphysis.  This  position  will  also 
keep  up  the  hypertrophy,  but  complete  procidentia  cannot  take  place 
unless  the  uterus  happens  to  become  retroverted.  But  Avith  no  sup- 
port at  the  outlet,  the  tissues  about  the  urethra  soon  thicken,  and,  in 
turn,  begin  to  prolapse.    This  relaxation  will  in  time  involve  the  whole 


368     PROCIDEXTIA,  OR  PROLAPSE  OF  THE  UTERUS. 

septum  between  the  vagina  and  bladder,  so  that  the  mass  will,  at 
length,  protrude  from  the  vagina  as  a  cystocele.  After  a  cystocele 
has  once  formed,  with  a  laboring  woman,  it  will  be  but  a  question 
of  time  before  the  uterus  becomes  retroverted.  This  displacement 
will  facilitate  a  prolapse  of  the  recto-vaginal  wall,  and  after  both 
a  cystocele  and  rectocele  have  formed,  the  procidentia  w^ll  soon  be 
complete. 

In  early  life,  even  with  extensive  laceration  of  the  perineum,  the 
formation  of  a  procidentia  is  not  the  rule  unless  the  woman  be  ex- 
posed to  the  risk  by  accident,  or  from  the  character  of  her  occupation. 
A  woman  with  a  moderate  degree  of  laceration  may  bear  a  number 
of  children  afterwards,  with  the  uterus  remaining,  between  each 
pregnancy,  enlarged  and  lying  on  the  floor  of  the  pelvis  for  years, 
without  any  apparent  increase  in  the  amount  of  prolapse.  At  length 
the  time  arrives  for  the  change  of  life,  and  nature  will  make  the 
attempt  to  bring  about  the  process.  Her  efforts  will  then  fail  in  di- 
minishing the  size  of  the  uterus,  and  the  period  will  only  be  recog- 
nized by  an  increase  in  the  length  and  quantity  of  the  menstrual  flow. 
Finally,  nature  accomplishes  what  she  can  in  bringing  about  the  usual 
changes  in  the  vagina,  by  which  the  posterior  cul-de-sac  disappears 
and  the  canal  becomes  shorter  and  lessened  in  diameter.  The  conse- 
quence is  that  the  uterus  is  brought  much  nearer  to  the  outlet  by  the 
shortened  vagina,  retroversion  naturally  follows,  and  it  then  requires 
but  little  more  exertion  to  complete  the  procidentia.  Then  the  uterus, 
being  relieved  from  any  obstruction  to  its  circulation,  soon  undergoes 
the  natural  change  and  becomes  atrophied,  but  the  displacement  of 
the  organ  continues  to  exist  unless  relieved  by  art. 

Etiology  of  Procidentia. — By  means  of  Table  XXXI.,  a  compari- 
son will  be  made  between  those  Avho  suffered  from  procidentia.  These 
were,  as  to  one  class,  treated  in  my  private  hosjjital,  and  as  to  another 
in  the  Woman's  Hospital.  With  the  one,  every  comfort  of  life  had 
been  enjoyed;  with  the  other,  want  had  doubtless  been  the  rule. 

Those  treated  in  the  private  hospital  had  had,  without  exception, 
the  advantage  of  the  best  medical  attendance  during  labor.  The 
contrary,  however,  was,  in  all  probability,  the  rule  Avith  the  greater 
number  of  those  admitted  to  the  Woman's  Hospital. 

This  table  does  not  include  all  who  were  treated  for  this  lesion  in 
the  Woman's  Hospital,  since  a  number  were  discarded  in  consequence 
of  some  serious  defects  in  their  record.  All  of  those  in  the  Woman's 
Hospital  were  operated  on  previous  to  May,  1872,  and  during  the 


PROCIDENTIA  IN  RELATION  TO  PRE<}NANCY,  ETC.         369 

time  I  had  charge  of  the  institution.     Those  from  my  pi'ivate  hospital 
were  treated  previous  to  Jan.  1874. 

In  explanation  of  Table  XXXI.,  we  will  take  as  an  example  the 
total  number  who  suftered  from  procidentia.  It  will  thus  be  shown 
that  in  both  institutions  86  cases  were  treated,  the  average  age,  at 
the  time  of  seeking  relief,  being  41.66  years.  Only  78  of  these  Avere 
able  to  give  the  age  at  which  the  menstrual  flow  first  made  its  appear- 
ance, and  a  still  smaller  number  the  date  of  marriage.  The  aver- 
ages, throughout  the  table,  are  calculated  on  the  number  placed  above 
them,  these  representing  the  actual  number  who  were  able  to  give  the 
information.  Of  these  86  women,  each  bore,  on  an  average,  3.82 
children,  and  21  of  them  had  a  certain  number  of  miscarriages  pre- 
vious to  the  labor  in  which  the  injury  was  supposed  to  have  been 
received.  Nineteen  of  these  afterwards  gave  birth  at  full  term  to 
children,  while  14  miscarried.  Altogether  these  86  Avomen  Avere  im- 
pregnated 438  times,  averaging  over  five  pregnancies  to  each  Avoman. 
With  85  of  these,  it  is  shoAvn  that  the  average  time,  previous  to 
admission,  and  since  the  reception  of  the  injury,  Avas  7.85  years.  A 
total  of  753  years  had  elapsed  since  the  last  pregnancy,  AA'hich  would 
give  an  aA^erage  of  8.85  years  for  each  woman.  It  Avill  be  seen  that 
20  women,  of  the  total  number  of  86,  had  already  gone  through  a 
change  of  life,  on  an  average  of  some  seven  years,  before  seeking 
relief,  and  at  the  average  age  of  46.80  years.  It  is  also  shown  that 
the  average  age  at  Avhich  the  injury  was  supposed  to  have  been  re- 
ceived was  over  33  years,  and  it  Avas  not  generally  until  after  the 
birth  of  the  second  child  that  the  injury  occurred. 

Finally,  the  connection  is  noted  between  the  time  of  undergoing 
the  change  of  life,  and  the  first  appearance  of  the  displacement.  Thus 
67  Avomen,  Avith  complete  procidentia,  had  first  noticed  the  displace- 
ment at  an  average  of  eight  years  or  more  before  seeking  relief,  and 
none  of  these  had  then  had  a  change  of  life.  But  Avith  17  Avomen 
this  change  had  already  occurred,  and  afterwards  at  the  average  age 
of  51.88  years,  the  procidentia  took  place. 

So  far  as  we  are  justified  in  draAving  any  deductions,  in  proof  of  a 
general  law  from  so  small  a  number,  it  is  evident  that  laboring  women 
seek  relief  at  an  earlier  age  than  those  in  the  upper  walks  of  life.  In 
consequence  of  a  life  more  exposed  to  hardship,  among  the  poorer 
class  of  Avomen,  a  gradual  prolapse  does  not  take  place  as  Avould  occur 
under  more  favorable  circumstances.  The  procidentia  becomes  com- 
plete much  earlier  in  life,  as  is  shown  by  the  comparatively  small 
number  who  are  found  suffering  only  from  rectocele  or  cystocele. 
34 


370 


PROCIDEXTIA,  OR  PROLAPSE  OF  THE  UTERUS. 


s 


^ 


(^ 


f^ 


'A 


•ajixjoaSuBija 
aq;  aa^j'B  sS'b 
aSBJaA-B  nB  ly 

12 

52.58 

5 
50.00 

■0 

47.60 
2 

48.50 

7 
47.8.3 

8 
46.25 

50.00 

to                     to       .c 

cc« 

=^co 

E5 

•ajHJoaSnBqo 
aqi  ejojsq 
anil]  triBjjao  y 

0        (M 

0  1=  t-  " 
1        «oKt- 

ofec-.§ 

'i'oo  —  l:- 

Tj<                     cc       to 
C5  "^                   C5  CC  C5  CO 

•=  00       t            0      to 

rt                    0      to 
cc  -^              c:  0  ,-  t- 

—  to          «>  C-.  ==  C-: 

0 

o 

o 

6 

"BauaoBid 
PditiB^aji 

:-  : 

" 

il       ■ 

:-  : 

- 

1             .      .r-i      . 

- 

:     1     : 

:"  : 

CO     .       j 

■nai 
-piiqo  agj^i 

- 

:-  : 

-^ 

CC 

1 

:-  : 

-1< 

:          :  :  :  : 

"* 

-  : 

•sniAij 

JO  SJIBJ 

C4 

•CO     • 

0 

1  ^ 

1 

•« 

:          :  :-  : 



i    = 

-*  • 

•noijOBJi 

« 

-  : 

^ 

-  : 

- 

:  :-  : 

cc 

^  : 

CO     . 

•gniTunj, 

CO     • 

« 

" 

eo 

:          :  :  :  : 

CO 

~  : 

'^     • 

■sdaojoj 

CO       • 

00 

] ,     •* 

-  : 

S 

-  :-  : 

<M 

K5 

S  : 

.T  : 

•suoipax 

^ 

"*  : 

:=; 

r    " 

-  : 

00 

CO 

.    .-cj    . 

■W     • 

-J< 

eq    ' 

•pidBH 

^ 

-- 

- 

oq    • 

'     :  :  :  : 

!  '^ 

Cl     . 

-V    • 

"X'Ejm'E^ 

^ 

■*  ; 

■= 

1 ;     « 

jl 

-  : 

■* 

-  :-  : 

-* 

1  - 

00    • 

cc    . 

■ 

•pajBjs  40^.; 

%  . 

t^  . 

•  -J<    ■ 

ef 

CO      . 

CO     . 
CI     • 

!    2  -'^  : 

S  : 

1  "?■>  • 

1      to    • 

to     . 

CO     . 
to     • 

1  pa.\iao3i  SB  A  A.in  f  nx  aqj 

CO  (N       i       00  eq  CO  n 

to  CI 

C-.  eq  C-,  CO 

00  Cl 

r~  0  ic  CI 

CJCT 

CI  0  CT  ". 

1         <=      "■ 

cc 

11  .-.s 

c  ci '-  — 

CO  0        1 
^  cc 

1                        -sjn  JO  S°TIBqO 

1     sonjs  sjBaX  niasBjaAV 

.0     •  -r; 

:S  :g 

I  to    !  -^ 

1 

;  "o 

I  CO     I  CO 

:•*■ 

;<5  ; to 

1 1>" 

•9jn  JO  a3n«q3  it3  aJgy 

.-q^.$ 

0        1         t^      0 
-  CO        ,      a^K^oi 

cc  cc 

1-      0 
oc  -"■  ^  c; 

-r      5 

W        CO 
TO  t^'  r-  cc 

-J"      -r 

1<to' 

•AOU'BTlSa.Td  5=1^7  8DUIS 

sjt;aA  JO  jaqman  ssBjoiy 

.  C3    .  o: 

t^co     1        ;i~;   •^• 

.  0 

.  to_ 

:  to 

.CI     .0 

•.id  :=-; 

:lg  :S 

.  CO 

•2   ! 

SDnis  amii  jo  TjjJnai 

0       c: 

»-•?  CO 

to       0  , 

2  =;  J]  =; 

f^  0 

(M         C. 
t-  0  0  t>;    ' 

to 

CO       to 
eo«=  coi- 

SS  1 

Number  of  proguanoios. 

■saion-BnSojri  jo 
jaqtnan  asBjaAy 

-  '^    !  -1' 

n 

;cc  : cc 

i      0    0 

cj  003  0 

:  cc 

1 

'.^ 

'.f       '.-!• 

;  -f 

'sb 

-saSBii 

CO  f-H  to  C> 

^s 

0 

0 

cc  ^ 

?»    • 

"2  '"= 

oS      ■ 

^  a" 

iiajpuqo 

ci  ""  ci 

K>                          L~        0     1 
0  CI                   1,-5  "C  =  CI 

"  ci              ^  ci""'  IN   1 

0          0 

cS 

j .          cc 
1      ec-c 

!'   '^ci 

-0  CI 

■'c-i 

Is 

K.2 

•sa;3Bu 

-aBOSTJI 

t^  ^  c^ 

"'  ei                ci      i-J 

0 

lies 

ci 

0 

Ci  r-l 

~  e-i 

•Tiajpitqg 

C-1  irj"  -"  ?^ 

'  ffj                   "^Cl  ''  Cl     1 

CI 

cc       0 
t^ci  00 

£-2 

0  '• 

0  CO 
00     . 
—  CO 

1            o 

•oSEIilBK    j 

^  'J?  ,-  ? 

CI 

C         CI 

COO 

0^ 

"l^""^ 

to  -*' 

f->Cl 

1 

•*  -«  « i~ 

I  CO       cc 

0 

d  cc 

1    ^2^E 

1 
•TjoissTtapy  ■ 

0         CO 
5,  SI  ^  ^ 

to 

r5       t- 
cc      cc 

Oi 

CO  ttJ 

cc 

o      0 

«cs 

2  ^*  ^  t^' 

'     '-'  i<      cc 

si 

[.  0  t.  0 

C    G    C    0 

P  >  s  > 

•^  r 

S  3 

p  >     1 

><  0  1-  » 

c;  ttc  be 
.0    g^  c! 

S  0  S  0 

C  >■  3   >. 

t,  0 

it 

"a 
0 

t.  0  u  0      t.  0 
0  tec  to      0  M 
.0  c;  .0;  (S     ^  s 

%-!.=•«         c   >- 

s  c-   C  0        C  c; 
,      s  >  •=  >      S  >■ 

-llil   1 

1                 i 

I.  0  I.  0        u  0 

0  it  c  ic      0  to 

ESSS      ES 

3   >    3  >         P  >• 

zi-Zi: 

llil  1 

llil 

0 
Eh 

Hi! 

I 

•Bijnappojj 

] 

■aiaoo^a 

^a 

j             -0180038.^0 

11             -i'^iox 

TREATMENT.  371 

The  woman  who  has  had  the  perineum  extensively  lacerated  may,  if 
properly  cared  for,  go,  as  shown  by  the  table,  for  over  two  years 
before  suffering,  and  then  average  eleven  years  before  the  procidentia 
becomes  sufficient  to  demand  relief.  But  if  she  be  a  washer- Avoman, 
or  in  a  station  of  life  where  she  cannot  be  cared  for,  she  will  bejrin  to 
suffer  in  less  than  two  months  after  the  labor,  and  will  be  unable  to 
work  longer,  on  an  average,  than  six  years  before  some  relief  becomes 
necessary. 

In  consequence  of  neglect  in  obtaining  the  necessary  information, 
or  from  inability  on  the  part  of  the  patient  to  furnish  it,  the  character 
of  the  labor  in  which  the  injury  was  received  has  unfortunately  not 
been  recorded  in  a  large  number  of  cases.  But  we  have  sufficient 
data  to  recognize  the  fact  that  artificial  delivery  was  practised  among 
the  poorer  classes  mucb  more  frequently  than  among  those  who  were 
better  able  to  command  the  time  of  the  medical  attendant.  If  we 
continue  the  comparison  between  the  two  stations  of  life  for  those 
cases  where  the  procidentia  has  become  complete,  it  Avill  be  seen  that 
the  woman  in  the  upper  walks  of  life  not  only  bore  more  children 
before  the  occurrence  of  the  accident,  but  during  her  whole  menstrual 
life  she  became  pregnant  a  greater  number  of  times.  A  greater 
portion,  if  not  all,  of  these  women  were  doubtless  in  perfect  health 
before  being  injured  in  childbirth.  Therefore,  these  averages  must 
be  very  near  correct.  The  average  number  of  children  for  both  classes 
is  greater  than  that  obtained  on  the  general  average  of  all  the  women 
under  observation.  The  average  age  of  puberty  for  the  women  treated 
in  the  private  hospital  is  essentially  the  same  as  that  obtained  on  the 
general  average,  and  may  be  accepted  as  being  very  near  the  proper 
one  for  the  better  class  of  women.  The  average  for  those  treated  in 
the  Woman's  Hospital  gives  evidence  of  a  much  later  development 
among  the  poorer  classes,  and  this  might  be  expected  from  what  has 
been  already  stated  on  the  subject  of  menstruation. 

Treatment  of  Procidentia. — Many  years  ago  I  formed  the  acquaint- 
ance of  a  shrewd  and  eccentric  physician,  I  believe  now  dead,  who 
lived  in  the  Currituck  district,  near  the  Virginia  border.  This 
gentleman  was  very  much  amused  at  the  surgical  procedure  I  em- 
ployed for  the  relief  of  procidentia,  and  did  not  hesitate  to  inform  me 
of  his  want  of  appreciation  of  it.  His  practice  was  almost  exclusively 
confined  to  the  negroes,  among  the  women  of  which  race  the  lesion  is 
common.  He  stated  that  he  could  cure  any  case  in  ten  days,  and 
had  employed  the  practice  for  many  years.  His  plan  was  to  swing 
the  woman  in  a  sling  from  a  beam,  in  the  knee  and  chest  position. 


372     PROCIDEXTIA,  OR  PROLAPSE  OF  THE  UTERUS. 

This  was  maintained  for  the  ten  clays,  during  which  time  the  vagina 
was  kept  filled  with  a  strong  decoction  of  oak  hark,  which  was  changed 
every  day  by  means  of  a  syringe.  He  assured  me  that  with  a  pro- 
perly padded  sling  there  was  no  difficulty,  for  the  woman  slept  all  the 
time,  and  was  not  disturbed  except  to  receive  her  food  or  answer  a 
call  of  nature.  From  others  I  have  since  learned  that  his  statement 
was  correct,  so  far  at  least  as  his  success  in  the  treatment  of  this 
displacement  was  concerned.  Although  this  plan  would  not  be  prac- 
ticable for  any  other  race,  and  is  so  but  to  a  limited  extent  among 
negroes,  yet  I  should  think  his  principles  of  treatment  were  correct. 

This  difficulty,  as  we  have  seen,  has  its  origin  in  consequence  of 
the  enlarged  uterus,  from  some  cause,  remaining  settled,  after  labor, 
on  the  floor  of  the  pelvis.  The  already  over-stretched  vagina  cannot 
regain  its  normal  size,  nor  the  uterine  litraments  recover  their  in- 
tegrity,  so  long  as  the  uterus  occupies  this  malposition,  and  acts  as  a 
wedge  to  continually  increase  the  dilatation. 

If  it  were  possible  to  lift  and  maintain  the  uterus  at  its  proper 
position  in  the  pelvis,  the  organ  would  be  able,  in  all  probability,  to 
regain  its  natural  size.  But  under  any  circumstances,  by  correcting 
this  position,  the  vagina  at  least  and  other  supports  of  the  uterus 
would  be  able  to  return  to  a  normal  condition.  With  a  large  and 
relaxed  vagina  this  cannot  be  done  by  any  mechanical  means  yet 
devised.  Beyond  a  certain  point  these  means  are  futile,  and  a  pes- 
sary, in  any  form,  will  prove  of  but  temporary  benefit,  and  in  the 
end  be  positively  detrimental.  AVhen  the  vaginal  walls  have  become 
very  much  relaxed,  it  is  impossible  to  prevent  them  from  crowding 
down  within  the  circumference  of  any  fenestrated  form  of  pessary. 
This  will  occur  to  an  extent  almost  producing  strangulation,  unless 
the  instrument  be  of  a  sufficient  length  to  put  the  passage  on  the 
stretch.  In  either  case  the  result  is  the  same  by  increasing  the 
capacity  of  the  vaginal  canal  and  by  adding  to  the  enlargement  of  the 
uterus  from  still  further  obstructing  the  circulation.  When  a  solid 
instrument  is  used,  the  capacity  of  the  canal  is  also  increased  by  the 
walls  crowding  in  around  it,  and  pressing  it  forward  as  a  dilator.  One 
instrument  after  another  will  be  resorted  to,  with  the  necessit}'-  of 
increased  size  for  relief,  until  the  canal  may  be  dilated  to  the  full 
extent  of  the  pelvic  passage.  The  patient  must  then  become  bed- 
ridden, or  she  may  be  relieved  of  the  most  urgent  symptoms  as  the 
uterus  escapes  from  the  vagina  and  the  procidentia  becomes  complete. 

Some  surgical  procedure  must  be  our  final  resource,  but  it  is 
always  advisable  to  administer  preparatory  treatment  previous  to  the 
operation.     Should  the  uterus  be  much  enlarged,  treatment  directed 


TREATMENT. 


373 


to  diminish  its  size  would  add  greatly  to  the  chances  for  success  from 
an  operation.  An  erosion  should  always  be  healed  beforehand,  and 
when  the  cervix  has  been  lacerated,  the  surfaces  should  be  united, 
since  this  surgical  interference  will  of  itself  greatly  reduce  the  size  of 
the  uterus.  It  is  necessary  to  antevert  the  uterus,  Avhich  is  usually 
retro  verted,  or  to  lift  it  from  the  floor  of  the  pelvis,  if  it  simply  sags 
from  increased  weight.  As  soon  as  the  uterus  is  placed  in  a  position 
where  the  circulation  can  again  become  established,  it  will  decrease 
rapidly  in  size.  It  will  often  prove  difficult  to  adjust  any  form  of 
pessary  for  correcting  a  retroversion,  where  the  perineum  has  been 
lost,  and  the  only  point  of  support  to  be  had  is  behind  the  symphysis. 
Yet,  by  having  the  patient  under  observation,  and  by  studying  the 
peculiarities  of  the  case,  it  can  be  accomplished.  Whenever  tender- 
ness on  pressure  can  be  detected,  iodine  must  be  applied  from  time  to 
time,  and  the  hot  water  vaginal  injections  steadily  employed.  We 
should  never  operate  under  any  existing  indication  of  cellulitis,  and 
whenever  there  is  detected  so  much  tenderness  at  any  point  as  to 
contra-indicate  the  use  of  a  pessary,  we  must  resort  to  other  means 
for  gaining  the  needed  support.  The  India-rubber  disk  may  some- 
times answer,  or  a  cotton  support  shaped  like  a  mushroom,  and 
saturated  with  glycerine,  to  be  renewed  daily.  Whenever  a  pessary 
is  employed,  it  must  be  watched  with  unusual  care,  for  when  such  a 
redundancy  of  tissue  exists,  a  fold  may  become  readily  strangulated 
or  packed  in  at  some  point,  so  as  to  cause  the  instrument  to  cut  into 
the  tissues  elsewhere,  as  if  it  were  too  large. 


Fig.  58. 


Block-tin  pessary  for  procidentia. 


For  procidentia,  I  have  used  a  home-made  instrument  which  has 
frequently  proved  of  great  service  in  my  hands.  I  have  some  block- 
tin  rings  of  from  six  to  nine  inches  in  diameter,  which  I  first  bend 
into  a  triangle  with  rounded  edges  (^A,  Fig.  58).     I  next  gradually 


374     PROCIDENTIA,  OR  PROLAPSE  OF  THE  UTERUS. 

bend  the  centres  of  each  side  towards  the  middle,  so  that  each  of  the 
three  openings  will  be  equal,  as  nearly  as  possible,  in  size  (B,  Fig. 
58).  The  instrument  is  then  completed  by  bending  over  ends  ah  e 
together,  and  then  flattening  the  instrument,  if  it  be  of  large  size, 
between  the  palms  of  the  hands,  so  that  it  will  be  about  one-third  less 
in  height  than  in  width  (C,  Fig.  58).  This  instrument  is  intended, 
when  not  needed  for  a  capacious  vagina,  to  be  of  the  same  size  and 
shape  on  all  sides,  as  I  have  attempted  to  show  in  the  portion  of 
figure  marked  C.  When  made  uniform  in  shape,  the  instrument  can 
scarcely  cut  at  any  point,  since  pressure  will  cause  it  to  roll  over,  or 
change  its  position.  It  is  intended  that  the  openings  should  be  large 
enough  to  admit  a  fold  of  tissue,  which  Avill  meet  in  the  centre  from 
each  side.  Since  it  is  impossible  for  a  very  large  fold  to  enter,  the 
tissues  cannot  become  strangulated.  The  vaginal  tissue  becomes 
literally  buttoned  into  the  instrument.  Although  the  tissues  are  fre- 
quently changing  their  position,  as  well  as  the  instrument,  yet  they 
never  become  disengaged  from  it,  and  when  the  proper  shape  has  been 
given  to  the  instrument,  it  can  scarcely  be  forced  out  of  the  vagina. 
I  have  seen  some  of  these  instruments  made  of  material  so  large  in 
diameter  as  to  be  worthless,  since  the  openings  were  thus  left  so  small 
that  the  tissues  could  not  enter  in  a  fold  sufficient  to  hold  it  in  place. 
Different  modifications  of  this  instrument  may  be  made  useful.  The 
end  A  may  be  opened  and  made  longer  than  the  other  two  portions, 
so  as  to  enter  the  cul-de-sac,  when  support  Avill  be  given  to  the  uterus 
from  behind  and  under  each  broad  ligament.  Instead  of  forming  a 
triangle  in  the.  first  instance,  a  larger  ring  may  be  used,  making  it 
square,  and  bending  the  four  corners  over  and  together  as  has  been 
described  for  the  triangle.  One  angle  can  then  be  opened  to  go  into 
the  posterior  cul-de  sac,  two  in  the  middle,  left  closed  to  support  the 
anterior  wall,  and  the  remaining  one  bent  back,  and  so  shaped  as  to 
give  support  to  any  rectocele  that  may  require  it.  For  rectocele 
alone,  I  have  sometimes  employed  another  form  when  the  support  is 
taken  from  behind  the  symphysis.  It  is  made  by  bending  together 
an  unusually  long  closed  lever  pessary,  as  in  Fig.  59,  so  that  more 
than  half  its  length  will  reach  just  beyond  the  cervix,  and  tlie  other, 
or  shorter  portion,  will  come  across  the  posterior  wall,  about  an  inch 
or  more  from,  the  vaginal  outlet.  Over  this  under  blade,  I  frequently 
stretch  an  India-rubber  band,  or  close  it  by  a  portion  of  thin  sheet 
lead,  such  as  is  found  in  tea  boxes.  The  portion  which  is  to  rest  near 
the  neck  of  the  bladder  must  have  a  proper  depression  made,  so  as 
not  to  exert  any  pressure  there,  and  the  corners  should  be  properly 


TREATMENT, 


375 


rounded  off.  When  this  instrument  is  well  fitted,  any  do\Ynward 
pressure  tilts  the  long  lever  up  behind  the  pubes,  and  prolapse  cannot 
take  place,  since  the  uterus  is  held  from  coming  forward,  and  the 
cross-bar  supports  the  rectocele.     The  material  for  these  temporary 


Fig.  59. 


Long  closed  lever  pessary  for  procidentia. 

instruments  should  always  be  block-tin,  since  this  will  admit  of  any 
necessary  change  of  shape.  When  the  pessary  has  been  introduced, 
if  of  block-tin,  two  fingers  can  be  inserted  into  the  vagina,  and  the 
sides  of  the  instrument  may  be  spread  apart  at  any  point,  or  narrowed 
if  necessary.  Whenever  the  patient  is  beyond  the  reach  of  the  per- 
sonal observation  or  control  of  the  physician,  the  prudent  course  would 
be  to  employ  only  the  India-rubber  disk,  or  the  cotton  support.  As 
has  been  stated,  the  use  of  pessaries  in  these  displacements  requires 
constant  observation,  and  yet,  in  spite  of  all  care,  the  patient  Avill 
sometimes  suffer.  One  precaution  is  necessary  on  removing  a  pessary 
or  the  cotton  support,  namely,  to  disengage  the  instrument  before 
withdrawing  it.  If  this  is  not  done,  the  uterus  is  alwavs  drao-o-ed 
down  to  the  outlet  before  it  becomes  filled,  and  consequently  but 
little  progress  Avill  be  made.  I  always  direct  the  patient,  when  re- 
moving it  herself,  to  pass  one  finger  on  each  side  of  the  cotton  dress- 
ing, so  as  to  afi"ord  some  support  to  the  parts  as  this  is  withdrawn. 

Frequently  some  attention  needs  to  be  directed  to  the  general  con- 
dition, and  it  is  always  absolutely  necessary  to  regulate  most  carefully 
the  condition  of  the  bowels. 

The  object  of  all  surgical  procedures  looking  to  the  cure  of  prolapse 
is  to  support  the  uterus  in  its  proper  place  in  the  pelvis,  until  it  has 
recovered  its  natural  size.  This  is  accomplished  by  turning  in  the 
excess  of  tissue,  and  uniting  freshened  surfaces  which  should  run  nearly 
parallel  on  either  or  both  walls  of  the  vagina,  and  then  properly  clos- 
ing the  perineum  at  the  vaginal  outlet,  so  as  to  give  suitable  support- 
from  below.  By  these  operations,  the  vagina  will  be  restored  to  its 
original  size  and  condition,  while  its  natural  capacity  cannot  be  im- 


376 


PROCIDENTIA,  OR  PROLAPSE  OF  THE  UTERUS. 


paired  by  them.  Their  object  is  simply  to  relieve  the  over-stretched 
tissues  from  strain,  that  they  may  retract.  This  is  done  by  taking  in 
a  plait,  by  which  means  the  tissues  thus  turned  in  may  regain  their 
tone,  and  in  a  few  months  all  trace  of  the  operation  disappears.  It  is  a 
common  impression  held  by  the  profession,  that  the  object  of  the  ope- 
ration is  to  narrow  the  vagina,  but  the  idea  is  erroneous,  and  a  mis- 
leading one.  This  canal  can  be  easily  shortened  by  uniting  denuded 
surfaces  transverse  to  its  axis.  But  to  narrow  the  vagina  in  its  diam- 
eter after  puberty  to  a  greater  degree  than  existed  in  the  virgin  state, 
is  impossible  by  any  surgical  procedure.  This  cannot  take  place  ex- 
cept as  a  result  of  inflammatory  action,  accompanied  by  sloughing, 
when  the  cicatricial  tissue  thus  formed  contracts  the  same  as  elsewhere. 
When,  by  chance,  the  denuded  surfaces,  to  be  brought  together  by 
this  operation,  are  so  far  apart  that,  when  they  are  approximated,  an 
undue  degree  of  tension  exists,  the  sutures  will  certainly  cut  out  and 
leave  the  parts  in  their  original  condition.  This  is  owing  to  the  un- 
yielding line  formed  along  the  vaginal  sulcus  on  each  side,  which  is 
connected  with  the  pelvic  fascia.     This  tissue,  from  its  elasticity  can 

be  stretched  to  a  certain  degree,  but  no  su- 
ture can  withstand  its  persistent  traction, 
beyond  a  few  days,  without  cutting  out. 

Marshall  Hall  many  years  ago  suggest- 
ed, but  did  not  himself  put  the  plan  in 
practice,  that  for  the  relief  of  procidentia 
two  denuded  strips  should  be  united  running 
parallel  on  each  side  from  near  the  cervix 
uteri  to  the  vaginal  outlet,  thus  making  a 
double  vagina  as  it  were.  This  operation, 
however,  failed  in  practice,  as  the  anterior 
wall  of  the  vagina  would  prolapse  and  grad- 
ually press  back  the  septum,  or,  by  pres- 
sure, excite  absorption  of  the  recently  united 
surfaces  until  sufficient  space  had  been  thus 
produced  for  the  escape  of  the  uterus.  Dr. 
Sims,  in  Feb.  1858,  brought  these  two  surfaces  together  to  overcome 
this  difficulty.  He  commenced  the  scarification  on  the  anterior  wall  of 
the  vagina,  near  the  neck  of  the  bladder,  making  the  denuded  surface 
diverging  from  a  common  point,  as  shown  by  the  diagram.  Fig.  60, 
extending  to  each  side  of  the  cervix  uteri  in  the  form  of  a  triangle. 
These  surfaces  were  brought  together  and  secured  in  the  median  lino 
with  interrupted  silver  sutures.     In  this  way  the  neck  of  the  uterus 


Sims's  operation  for  procidentia. 


TREATMENT.  377 

was  crowded  towards  the  posterior  cul-de-sac,  and  the  fold  of  var^inal 
tissue  thus  formed  in  front  of  the  cervix  effectually  prevented  any 
prolapse  of  the  organ. 

Shortly  after  I  took  charge  of  the  Woman's  Hospital,  in  September 
1862,  and  before  Dr.  Sims  had  reached  Europe,  whither  he  had  gone 
to  reside,  one  of  the  first  patients  operated  on  by  him,  after  the  method 
described  above,  applied  for  relief.  She  stated  that  during  four  years 
she  had  been  entirely  relieved  by  the  operation.  About  three  months 
before  her  admission,  while  in  the  act  of  lifting  something,  she  had 
been  suddenly  seized  with  a  tenesmus,  which  became  persistent,  and 
that  her  suffering  had  been  continuous  since  that  time.  On  examina- 
tion,  I  found  the  line  of  union  was  prefect  and  with  no  prolapse  of  the 
vaginal  wall.  But  the  neck  of  the  uterus  had  slipped  into  the  pouch 
behind  the  septum  formed  by  the  operation,  with  the  effect  of  throw- 
ino;  the  fundus  into  the  hollow  of  the  sacrum,  and  fixing  the  organ  in 
this  position.  With  difficulty  the  neck  was  disengaged,  and  after  re- 
turning the  uterus  to  its  normal  position,  immediate  relief  was  obtained. 
On  reflection  it  became  evident  that  this  accident  would  be  of  frequent 
occurrence.  As  soon  as  the  uterus  diminished  sufficiently  in  size,  so 
that  its  neck  was  no  longer  grasped  by  the  fold  formed  in  front  of  it, 
the  latter  would  naturally  override  the  cervix  and  force  it  into  the 
pouch.  On  examining  two  other  cases,  which  I  had  operated  on  within 
the  previous  eighteen  months,  I  found  the  neck  already  behind  the 
fold  in  each  instance. 

On  the  tenth  of  October,  1862,  I  operated  on  one  of  these  cases  to 
overcome  the  difficulty.  I  closed  the  triangle  by  running  a  denuded 
strip,  as  a  base  to  the  triangle,  across  in  front  of  the  cervix  uteri. 
By  this  plan  I  connected  the  two  diverging  lines,  shown  in  Fig.  60, 
and  effectually  prevented  the  possibility  of  an  entrance  into  the  pouch. 
Dr.  Sims  subsequently  followed  this  plan,  as  practised  by  me,  leaving, 
ho'wever,  a  small  opening  in  the  cross  section,  immediately  in  front  of 
the  cervix,  which  from  its  position  might  be  objectionable.  For  some 
seven  years  afterwards  I  followed  this  method  with  but  little  change. 
I,  however,  appreciated  that  the  operation  could  never  come  into 
general  use  on  account  of  the  difficulties  to  be  overcome,  and  in  con- 
sequence of  the  necessity  for  constant  practice. 

Early  in  1869  I  attempted  to  simplify  the  operation,  and  then 
adopted  a  method  which  I  have  since  followed.  I  first  antevert  the 
uterus  with  my  finger,  as  the  patient  lies  on  the  back.  The  neck  of 
the  uterus  is  then  kept  crowded  up  into  the  posterior  cul-de-sac  by  a 
sponge  probang  in  the  hand  of  an  assistant,  while  the  patient  is  being 


378 


PROCIDENTIA,  OR  PROLAPSE  OF  THE  UTERUS. 


placed  on  the  left  side  for  the  introduction  of  the  speculum.  I  then 
endeavor  to  find  some  point,  about  half  an  inch  to  either  side  of  the 
cervix  and  a  little  behind  the  line  of  its  anterior  lip,  which  two  points 
can  be  drawn  together  in  front  of  the  uterus  by  a  tenaculum  in  each 
hand.  When  two  points,  as  triangular-shaped  folds,  can  be  thus 
brought  together  without  undue  tension,  the  surfaces  are  to  be 
freshened.  One  of  the  tenacula  securely  hooked  in  the  tissues,  to 
indicate  the  point,  must  be  released  from  the  hand  for  the  purpose  of 
denuding,  with  a  pair  of  scissors,  a  surface  half  an  inch  square  about 
the  point  held  by  the  other  tenaculum.  Then  a  similar  surface  is  to 
be  freshened  around  the  point  of  the  first  tenaculum,  and  a  strip  after- 
wards removed  from  the  vaginal  surface,  in  front  of  the  uterus,  about 


Fig.  61. 


Folds  formed  in  the  operation  for 
procidentia. 


Author's  operation  for  procidentia. 

an  inch  long  by  half  the  width  (see  Fig. 
61).  Having  passed  a  needle,  armed  with 
a  silk  loop,  beneath  each  of  these  freshened 
surfaces,  as  shown  in  Fig.  62,  a  silver  wire 
is  to  be  attached  to  the  loop  and  secured 
by  twisting,  —  thus  bringing  together  in 
front  of  the  cervix,  as  will  be  seen  in  Fig. 

61,  these  three  points,  with  the  effect  of  forming  a  similar  fold,  but 
somewhat  smaller  than  that  formed  by  Dr.  Sims's  method.  The  chief 
advantages  gained,  apart  from  simplifying  the  operation,  are  these : 
With  the  loss  of  only  a  few  drops  of  blood,  the  neck  of  the  uterus,  at 
the  beginning  of  the  operation,  can  be  secured  in  the  cul-de-sac,  and 
we  can  thus  dispense  Avith  the  hand  of  an  assistant,  which  must  neces- 
sarily be  in  the  way.  By  the  old  operation,  the  tissues  forming  the 
fold  were  drawn  from  behind,  and  wrapped  around  in  front  of  the  cer- 
vix, while  the  chief  support  was  from  the  column  formed  in  the  median 
line,  by  turning  in  the  redundant  tissues  below.  By  the  method  I 
have  adopted,  a  direct  lateral  support  is  gained  from  the  pelvic  fascia, 
giving,  in  many  cases,  by  this  means  alone,  a  sufficient  support,  entirely 


TREATMENT.  379 

independent  of  the  column  to  be  afterwards  formed  from  the  tissues 
turned  in  along  the  anterior  -wall.  Completion  of  the  operation,  after 
having  fixed  by  this  means  the  position  of  the  cervix,  is  very  simple. 
Fig.  62  shows  the  formation  of  two  folds  on  the  anterior  wall,  in  the 
shape  of  an  ellipse,  extending  from  the  surfaces  secured  in  front  of 
the  uterus  nearly  to  the  vaginal  outlet.  This  excess  of  tissue  is  to 
be  turned  in  by  finding,  Avith  tenacula,  from  time  to  time,  opposite 
points  near  the  crest  of  each  fold,  which  can  be  brought  together 
without  tension.  With  the  object  of  preventing  any  unnecessary 
loss  of  blood,  but  half  an  inch  on  each  side  need  be  denuded  at  a 
time,  into  which  the  sutures  are  to  be  introduced  and  secured. 
Thus  advancing  step  by  step,  complete  the  operation  by  turning  in 
these  folds,  until  at  length  they  become  lost  on  the  vaginal  surface 
near  the  neck  of  the  bladder.  From  four  to  five  sutures  should  be 
inserted  to  the  inch,  a  silk  loop  being  passed  first,  to  which  the  silver 
suture  is  to  be  attached  for  the  purpose  of  drawing  it  through.  The 
needle  should  be  introduced  so  as  to  include  a  liberal  amount  of  tissue, 
and  the  sutures  twisted  only  just  suificiently  to  bring  the  raw  surfaces 
in  contact,  that  strangulation  may  be  avoided  from  th^.  swelling  of  the 
parts.  The  sutures  are  usually  removed  on  the  eighth  to  the  tenth 
day.  No  special  after-treatment  is  needed,  beyond  keeping  a  self- 
retaining  sigmoid  catheter  in  the  bladder  until  the  parts  have  become 
well  united.  When,  from  any  circumstance,  the  catheter  cannot  be 
retained,  the  bladder  should  be  emptied  every  few  hours,  so  that  the 
weight  of  a  quantity  of  urine  may  not  be  borne  by  the  recently  united 
surfaces.  If  it  be  necessary  to  empty  the  bladder  on  a  bed-pan,  a 
little  tepid  water  should  be  thrown  into  the  vagina  immediately  after- 
Avards,  for  fear  that  some  urine  may  have  passed  in ;  by  this  method 
its  effects  on  the  uniting  surfaces  would  be  neutralized.  It  is  abso- 
lutely necessary  to  confine  the  patient  to  the  recumbent  position  for 
two  or  three  weeks. 

Where  the  upper  portion  of  the  vagina  only  has  become  dilated 
from  an  enlarged  uterus  resting  on  the  floor  of  the  pelvis,  I  often 
operate  for  the  prolapse  in  preference  to  using  a  pessary.  The  ope- 
ration, in  principle,  is  essentially  the  same  as  that  described  for  the 
relief  of  procidentia.  The  line,  however,  formed  from  the  turning  in 
of  the  superabundant  tissue,  only  extends  for  a  short  distance  on  the 
anterior  wall,  since  but  a  limited  portion  of  the  canal  is  dilated. 
Frequently,  not  more  than  two  or  three  sutures  are  needed,  but  the 
line  must  be  extended  until  a  point  has  been  reached  woere  the  folds 
can  be  terminated  on  a  common  level  with  the  vaginal  surface.     In 


380     PROCIDENTIA,  OR  PROLAPSE  OF  THE  UTERUS. 

other  words,  as  only  the  upper  portion  of  the  vagina  is  dilated,  there 
will  be  less  and  less  tissue  to  turn  in,  and  the  folds  will  gradually 
become  smaller  towards  the  vaginal  outlet  until,  at  length,  they  will 
be  lost  or  smoothed  out,  as  it  were. 

When  there  is  no  laceration  of  the  perineum,  or  dilatation  of  the 
vaginal  outlet  from  rectocele,  the  operation  described  as  applicable 
for  the  anterior  wall  may  be  of  itself  sufficient  to  cure  a  partial  pro- 
cidentia. If,  however,  the  posterior  portion  of  the  canal  has  been 
involved,  the  uterus  will  gradually  advance,  and  ultimately  escape 
from  the  vagina.  This  it  will  do  even  after  the  operation  has  been 
performed  successfully  in  every  detail  as  described.  Unless  there 
exists  a  proper  support  below,  no  operation  yet  devised  for  the  ante- 
rior wall  of  the  vagina  can,  of  itself,  prevent  a  prolapse  of  the  uterus. 
Under  such  circumstances,  the  sole  purpose  of  such  an  operation  is  to 
increase  the  radial  distance  between  the  cervix  and  neck  of  the  bladder. 
Then,  if  the  uterus  cannot  become  retroverted,  nor  approach  near  to 
the  symphysis,  it  will  only  prolapse  in  the  circle  incident  to  the  radius 
thus  gained.  If  the  outlet  of  the  vagina  be  sufficient,  the  procidentia 
may  become  complete  again  very  soon  after  an  operation.  Yet,  such 
an  operation  may  have  been  a  success,  so  far,  at  least,  that  the  rela- 
tive distance  between  the  cervix  uteri  and  the  neck  of  the  bladder,  as 
gained  by  the  operation,  remained  unchanged.  While  the  radial 
distance  between  these  two  points  is  preserved,  the  base  of  the  bladder 
Avill  swing  like  a  trap  door,  as  if  it  were  hinged  under  the  pubes.  It 
will  advance  with  the  uterus,  as  the  latter  is  dragged  down  by  the 
prolapsing  posterior  wall,  to  pass  through  the  vaginal  outlet  as  soon 
as  this  has  become  sufficiently  dilated.  This  condition  is  commonly 
not  appreciated,  and  the  operative  procedure  is,  in  consequence, 
frequently  condemned,  and  unjustly.  I  will  then  repeat,  that  the 
prolapse  may  be  relieved,  in  consequence  of  the  increased  radius 
gained  by  the  operation  between  the  cervix  and  the  symphysis  pubis, 
as  a  common  centre,  provided  the  lower  portion  of  the  canal  remains  in 
a  state  of  integrity.  When  such  is  not  the  case  no  permanent  benefit 
will  be  obtained  unless  the  perineum  be  closed  and  the  rectocele  re- 
moved, if  necessary. 

The  operation  on  the  posterior  wall  for  rectocele,  as  formerly  prac- 
tised, resembled  closely,  m  general  principles,  the  one  already  de- 
scribed. The  denuded  surfaces  extended  from  the  fourchettc  upward, 
in  the  form  of  an  ellipse,  towards  the  cul-de-sac,  and  were  continued 
out  until  the  excess  of  tissue  was  turned  in  level  with  the  vaginal  wall. 
The  operation  was  a  very  difficult  one  to  perform,  from  the  want  of 


CYSTOCELE, 


381 


space,  and  the  venous  hemorrhage  was  frequently  excessive.  Besides, 
it  so  often  proved  unsatisfactory,  that  I  finally  adopted  a  procedure 
by  which  the  rectocele  might  he  removed  and  the  perineum  closed  by 
a  single  operation.  This  will  be  fully  explained  in  connection  with 
the  operation  for  laceration  of  the  perineum. 

Cystocele  is  frequently  met  with  in  women  advanced  in  life,  when 
an  operation  on  the  anterior  wall  would  be  sufficient  for  its  relief, 
without  closing  the  perineum,  although  the  loss  of  the  perineum  was 
the  original  cause  of  the  difficulty.  When,  however,  the  procidentia 
did  not  become  complete  at  the  change 
of  life,  the  prolapse  of  the  anterior 
wall  Avas  not  likely  to  be  increased 
afterwards,  as  the  then  diminished  size 
of  the  vagina  afforded  the  necessary 
support. 

For  the  relief  of  a  simple  cystocele, 
Dr.  Sims' s  operation  will  be  sufficient. 
This  consists  in  the  removal  of  a  portion 
of  the  mucous  membrane  in  the  form 
of  an  ellipse,  as  shown  in  Fig.  63. 

The  patient  is  to  be  placed  on  the 
left  side,  and  the  speculum  introduced. 
With  a  sound  properly  curved  for  two 
or  three  inches  of  its  length,  the  excess 
of  tissue  can  be  pressed  back  in  the 
median  line  towards  the  bladder,  and 

thus  held  by  an  assistant.  Two  long  folds  will  be  formed,  from  which 
it  will  be  now  necessary  to  remove,  with  a  pair  of  scissors,  small  por- 
tions of  tissue  along  their  crest,  to  serve  as  guides  in  the  operation. 
When  the  tissues  are  again  allowed  to  roll  out,  it  will  be  easy  to  cor- 
rect these  points  by  removing  the  intervening  strips  of  vaginal  mucous 
membrane.  These  freshened  surfaces  are  to  be  united  by  interrupted 
sutures  along  the  median  line,  and  secured  in  the  usual  manner. 

But,  whenever  the  parts  about  the  urethra  have  become  prolapsed 
and  thickened,  this  operation  does  not  always  answer.  The  difficulty 
is  that  it  cannot  remove  this  excess  of  tissue  about  the  urethra,  even 
if  the  line  be  extended  to  the  meatus.  Under  these  circumstances,  I 
now  remove  the  mucous  membrane  from  the  vaginal  surface  in  the 
form  shown  in  Fig.  64.  Only  a  single  suture  is  represented  as 
having  been  introduced,  so  as  not  to  confuse  the  demonstration.  If 
this  suture  passing  through  the  apex  of  each  triangle  were  secured, 


Sims's  operation  for  cystocele. 


382 


PROCIDENTIA,  OR  PROLAPSE  OF  THE  UTERUS. 


the  two  points  AB  would  be  drawn  together,  and  at  the  same  time 
the  flap  B  would  carry  with  it  the  excess  of  tissue  about  the  neck  of 
the  bladder.  This  would  occur  on  account  of  the  uterus  beino;  the 
least  yielding  point.     The  sutures  would  all  radiate  somewhat  from 

Fig.  65. 


\  B 


Emmet's  operation  for  cystocele. 


Position  of  the  flaps. 


the  point  B  (Fig.  64),  and,  Avhen  secured,  the  line  of  union  would 
form  the  triangle  CAD.  In  this  operation  it  is  necessary  to  pass  the 
sutures  so  as  to  include  a  liberal  amount  of  tissue,  and  they  should 
be  allowed  to  remain  m  situ  ten  or  twelve  days.  We  aim  to  utilize 
the  unusual  amount  of  traction  which  is  brought  into  play  by  this 
operation,  to  correct  the  prolapse.  It  is,  therefore,  necessary  to  take 
this  precaution,  since  the  sutures  are  very  liable  to  cut  out. 

For  procidentia,  with  an  excess  of  tissue  prolapsing  about  the 
urethra,  I  adopt  the  same  method,  but  somewhat  modified.  About 
two-thirds  of  the  line,  from  the  uterus  forward,  is  united  in  the  usual 
manner  to  the  point  A  (Fig.  64).  The  operation  is  then  begun  by 
removing  the  tissue  about  the  urethra.  It  is  necessary,  as  a  first 
step,  to  ascertain  by  means  of  a  tenaculum  how  much  of  the  tissue 
can  be  drawn  up  in  the  form  of  a  triangular  flap  to  the  point  A. 
When  this  flap  has  been  secured,  by  twisting  the  suture  AB,  two 
folds  will  be  formed  on  each  side  extending  towards  the  imier  face 
of  each  ramus.  With  a  tenaculum  in  each  hand,  we  are  to  judge 
how  much  tissue  should  be  turned  in.  Then,  when  the  sutures  have 
all  been  twisted,  we  will  have  the  additional  lines  AB  and  AC,  as 


TREATMENT.  383 

shown  in  Fig.  65.  This  plan  of  operating  disposes  most  effectually 
of  all  excess  of  tissue,  and,  when  union  has  been  obtained,  the  sup- 
port is  perfect,  since  it  is  exerted  in  all  directions.  But  with  all 
its  advantages,  one  difficulty  remains  which  I  have  never  been  able 
to  overcome.  In  consequence  of  the  traction  exerted  in  opposite 
directions,  the  three  flaps  brought  together  almost  always  separate  to 
some  extent  at  the  angle  A  after  the  sutures  have  been  remov^ed,  and 
this  necessitates  a  second  operation. 


384  LACERATION  OF  THE  PERINEUM. 


CHAPTER    XX. 

LACERATION  OF  THE  PEEIXEUM. 

Effects  of  laceration — Mode  of  operating — Introduction  of  the  sutures  and  securing 
the  wires — Laceration  through  the  sphincter — Mode  of  operating — Causes  of 
failure — Table  XXXIL,  showing  relation  of  laceration  through  the  sphincter  to 
age,  pregnancies,  labors,  etc. 

The  importance  of  having  the  perineum  intact,  and  its  influence  on 
the  healthy  condition  of  the  nervous  system,  is  not  fully  appreciated. 

"When  extensively  lacerated  and  prolapse  occurs,  it  is  easy  to  recog- 
nize an  obvious  cause  of  suffering.  But  we  meet  with  cases  compli- 
cated by  nervous  disturbances,  due,  experience  teaches  us,  to  the 
existence  of  this  lesion,  but  Avithout  prolapse,  and,  it  may  be  so  stated, 
■without  our  being  able  to  afford  a  definite  explanation  of  cause  and 
effect.  This  condition  -will  sometimes  be  accompanied  by  a  general 
irritability,  which  cannot  be  traced  to  any  other  local  cause,  and  is 
only  relieved  by  restoring  the  perineum.  I  have  known  of  several 
instances  in  which  the  existence  of  a  scar  on  the  perineum  excited  so 
much  reflex  irritation  as  to  entirely  change  the  disposition  of  the 
Avoman,  and  yet  she  was  not  conscious  of  any  local  difficulty. 

The  perineum  is  liberally  supplied  with  bloodvessels  and  nerves, 
together  with,  I  suspect,  branches  from  the  sympathetic  system,  since 
these  are  so  freely  distributed  to  the  neighboring  erectile  tissues.  If 
it  be  demonstrated  that  these  parts  receive  such  nerves,  an  explanation 
is  found  for  the  reflex  irritation  so  often  produced,  and  the  presence 
of  the  cicatricial  tissue  is  a  sufficient  exciting  cause.  That  reflex 
irritation  may  emanate  from  the  perineum,  as  the  effect  of  a  local 
exciting  cause,  cannot  be  questioned.  It  is  a  well-known  fact  that 
contractions  of  the  uterus  can  be  excited,  during  the  progress  of  a 
labor,  by  pressure  on,  or  by  stretching  back,  the  perineum.  When- 
ever a  laceration  has  been  extensive,  so  as  to  have  a  dense  cicatricial 
surface  on  the  perineum,  the  most  profound  degree  of  anaasthesia  can 
scarcely  allay  the  irritation  excited  by  the  necessary  traction  Avhile 
using  Sims's  speculum.  I  have  been  obliged  to  defer  an  operation 
for  vesico-vaginal  fistula,  where  the  perineum  was  in  this  condition, 
although'  the  patient  had  been  fully  etherized.     For,  as  soon  as  the 


ANATOMY.  385 

slightest  traction  was  made  by  the  speculum  on  the  perineum,  the 
patient  would  immediately  stretch  out  to  full  length,  and  could  not  be 
held  in  position  by  force.  I  have  been  obliged  to  operate  on  these 
cases  afterwards,  the  patient  being  under  the  influence  of  opium,  and 
free  to  exercise  her  voluntary  control. 

When  the  perineum  has  been  lacerated  down  to  the  fibres  of  the 
sphincter  ani  muscle,  there  remains  no  support  to  the  uterus  while 
the  woman  is  in  the  upright  position,  except  through  the  connective 
tissue  and  the  utero-sacral  ligaments.  As  she  stands  erect,  with 
this  condition,  a  perpendicular  line  from  the  front  of  the  sphincter 
ani  would  pass  through  the  posterior  lip  of  ihe  uterus  or  even  behind 
it.  The  uterus  is  thus  suspended  over  a  constantly  dilated  and  re- 
laxed cavity,  and  with  this  state  of  things,  it  cannot  surprise  us  that 
before  a  very  long  period,  complete  prolapse  of  the  uterus  will  take 
place.  Yet  it  is  sometimes  observed  that,  with  extensive  laceration, 
there  exists  neither  disturbance  of  the  nervous  system  nor  any  dis- 
comfort which  could  be  attributed  to  a  want  of  support.  But  these 
cases  are  certainly  only  the  exception,  while,  sooner  or  later,  they 
all  come  under  the  same  general  rule. 

So  long  as  the  perineum  exists  in  its  integrity,  the  sides  of  the 
vagina  lie  in  close  contact,  from  being  flattened  laterally,  and  air  is 
excluded.  The  sides  of  the  canal  are  thus  kept  in  contact,  from  their 
lateral  attachment  to  the  connective  tissue  of  the  pelvis,  and  the  pelvic 
fascia  is  attached  at  the  vaginal  outlet  just  as  the  canal  becomes  joined 
with  the  labia.  The  upper  and  lower  Avails  of  the  canal  are  thus 
brought  together,  the  same  as  the  sides  of  an  elastic  tube  would  be  by 
making  lateral  traction  with  the  fingers  in  a  direction  similar  to  that 
exerted  by  the  connective  tissue  around  the  vagina. 

In  laceration  of  the  perineum  the  ischio-perineal  ligaments  are 
divided,  and  the  transverse  perinei  muscles  and  other  attachments 
draw  the  sides  of  the  vaginal  outlet  apart.  The  connective  tissue  of 
the  pelvis  can,  therefore,  no  longer  exercise  the  same  support,  nor 
in  the  same  direction  as  before  laceration,  so  that  the  canal  remains 
patulous. 

I  am  satisfied  that  the  perineum  is  frequently  lacerated  on  the  vagi- 
nal surface,  without  the  fissure  extending  through  to  the  skin,  and 
that  this  is  done  by  splitting  through  a  fold  of  vaginal  tissue  which 
may  be  found  in  advance  of  the  child's  head  just  before  birth.  This 
lesion,  however,  seems  to  extend  deep  enough  to  divide  the  central 
attachment  of  the  ischio-perineal  ligaments,  with  the  eifect  of  leaving 
the  vaginal  outlet  flaccid  and  depriving  it  of  its  proper  support. 
25 


386  LACERATION    OF    THE    PERINEUM. 

The  great  discomfort  which  is  experienced  sometimes,  even  before 
any  prolapse  has  been  detected,  must  be  due  to  over-distension  of  the 
bloodvessels,  the  coats  of  -which  are  no  longer  properly  supported, 
the  sensation  being  due  to  increased  pressure  on  nerve-fibres.  This  is 
a  condition  in  itself  likely  to  prove  an  important  factor  in  displacing 
the  uterus,  in  consequence  of  the  increased  weight,  and  by  exciting 
tenesmus. 

Whenever  the  perineum  has  been  lacerated  so  that  the  proper  degree 
of  support  to  the  vaginal  walls  is  no  longer  exerted,  there  can  be  no 
doubt  as  to  the  necessity  for  an  operation  to  restore  the  parts  to  their 
original  condition.  There  are  cases,  however,  where  a  doubt  as  to 
this  necessity  may  remain  even  after  a  careful  examination.  After 
the  occurrence  of  the  accident,  and  if  the  vagina,  as  has  been  described, 
becomes  a  patulous  canal,  the  air  will  enter,  or  be  displaced  from  the 
passage,  with  every  movement  of  the  body.  In  case  of  doubt  as  to 
the  propriety  of  an  operation  I  question  the  patient  in  regard  to  this 
circumstance :  I  always  operate  when  I  learn  that,  on  suddenly  turning 
in  bed,  or  on  making  any  quick  movement,  the  patient  had  observed 
the  air  to  escape  from  the  vagina,  as  flatus  would  from  the  anus. 

I  have  already  described  at  length,  that  the  support  of  the  perineum 
is  essential  to  the  cure  of  all  cases  of  prolapse,  and  that  no  surgical 
procedure  or  mechanical  resource  will  prove  of  permanent  benefit  so 
long  as  any  degree  of  rectocele  exists. 

In  my  practice  I  have  found  it  necessary  to  close  the  perineum  for 
one  hundred  and  fifty-fovir  women  of  the  number  who  suffered  from 
the  different  stages  of  procidentia.  To  impress  this  fact  I  will  state 
that,  of  one  hundred  and  eighty  women  having  rectocele,  cystocele,  or 
complete  procidentia,  the  perineum  was  closed  by  me  (in  addition  to 
other  operations)  in  all  but  twenty-six  cases.  Where  the  operation 
had  been  deemed  unnecessary,  it  was  found  to  be  almost  entirely 
among  those  who  had  cystocele  only,  and  after  a  change  of  life  had 
already  taken  place  previous  to  the  operation. 

For  over  twenty  years  I  have  been  in  a  position  where  I  could  ob- 
serve the  value  of  each  surgical  procedure  devised  for  the  relief  of 
these  difficulties,  and  appreciate  the  changes  brought  about  by  time, 
the  most  valuable  test  of  all.  This  experience  has  taught  me  that 
whenever  the  procidentia  had  been  complete,  the  displacement  recurred, 
I  believe,  in  every  instance  when  the  perineum  had  not  been  closed, 
unless  a  change  of  life  had  already  taken  place.  The  longest  instance 
under  my  observation,  before  the  recurrence  of  the  procidentia,  and 
where  the  support  of  the  perineum  was  wanting,  was  about  four  years.    I 


OLD    OPERATIONS.  387 

find  that,  even  after  carefully  closing  the  perineum,  as  the  final  ope- 
ration, the  procidentia  would  soon  return  if  the  uterus  was  left  retro- 
verted,  unless  it  so  happened  that  the  organ  became  bound  down  by 
adhesions.  I  observed  also  that  there  was  a  new  condition,  to  be 
again  referred  to,  which  was  left  after  the  old  method  of  operating  for 
rectocele.  This  frequently  reproduced  the  procidentia,  by  bringing 
about  absorption  of  the  perineum,  and  led  me  to  adopt  the  operation 
Avhich  I  will  describe  further  on. 

Mode  of  Operating  for  Laceration  of  the  Perineum. 

The  mode  of  operating,  as  practised  by  Baker  Brown  and  those  who 
preceded  him,  was  of  no  value  for  the  purpose  of  giving  support  to  the 
vaginal  walls,  since  only  the  sides  of  the  labia  were  united.  By  this 
method  no  connection  was  re-established,  even  indirectly,  with  the  fascia 
and  deep  tissues  of  the  pelvis.  As  a  consequence,  the  soft  parts,  thus 
brought  together,  soon  became  stretched  and  thinned  out,  leaving  the 
vaginal  outlet  as  patulous  as  before.  The  quill  and  silk  suture  Avas 
in  general  use,  and  it  was  deemed  necessary  to  divide  the  sphincter  ani 
muscle,  and,  often  lateral  incisions  were  made  into  the  soft  parts  to 
relieve  the  tension.  In  this  tissue  about  the  vaginal  outlet  it  was 
impossible  to  regulate  the  degree  of  pressure  with  any  even  distribu- 
tion along  the  quill,  so  that  sloughing  and  erysipelas  frequently 
occurred.  With  the  use  of  silk  in  this  vascular  tissue,  the  formation 
of  abscess  was  of  more  frequent  occurrence  than  is  now  found  to  be 
the  case  with  the  metallic  suture.  Moreover,  the  division  of  the 
sphincter,  and  the  incisions  made  into  the  soft  parts,  have  proved  to 
be  unnecessary,  and  they  complicate  the  after-treatment  exceedingly. 

Dr.  J.  B.  Mettauer,'  of  Virginia,  was,  I  believe,  the  first  on  record 
Avho  employed  metallic  interrupted  sutures  in  this  operation  ;  he  used 
them  with  success  as  early  as  1830.  He  somewhat  modified  the 
application  of  the  leaden  ligatures  of  Dieffenbach,  and,  I  believe,  did 
not  divide  the  soft  parts.  Dr.  Sims  substituted  the  silver  wire  for 
the  leaden  wire  of  Mettauer  in  this  operation,  and  this  was  certainly 
a  great  advance.  He  did  not  divide  the  sphincter,  or  think  it 
necessary  to  make  incisions  to  relieve  the  sutures,  but  in  no  other 
respect  did  his  mode  of  operating  differ  from  that  generally  practised. 

On  taking  charge  of  the  Woman's  Hospital,  in  the  autumn  of  18(32, 
I  began  a  series  of  observations  in  regard  to  this  operation,  but  more 
particularly  for  the   condition  involving  the  sphincter   ani.     I  soon 

'  Amer.  Journ.  of  Med.  Sciences,  Philadelphia,  1833. 


388  LACERATION    OF    THE    PERINEUM. 

reached  the  conclusion  to  which  every  observer  must  arrive,  that  to 
gain  the  proper  amount  of  support  it  is  necessary  to  include  a  certain 
portion  of  the  vaginal  tissue.  From  that  time  until  the  spring  of 
1875,  I  included  the  posterior  wall  of  the  vagina  to  the  level  of  the 
sulcus,  in  all  the  sutures,  with  the  exception  of  the  uppermost  two, 
which  were  used  simply  to  bring  together  the  sides  of  the  labia.  I 
have  since  then  included  a  portion  of  the  vaginal  tissue  in  all  the 
sutures.  Previous  to  the  spring  of  1875,  it  had  been  my  practice  to 
employ  a  special  operation  for  the  relief  of  the  rectocele.  The  excess 
of  tissue  was  turned  in  along  the  median  line,  and  secured  by  inter- 
rupted sutures  until  the  vaginal  outlet  was  reached,  when  the  peri- 
neum was  closed  up  to  the  terminal  point  of  the  previous  operation. 
If  the  one  operation  followed  the  other,  several  of  the  perineal  sutures 
were  passed  in  the  space  between  as  many  of  the  lower  sutures  used 
for  closing  the  rectocele.  But  the  prolapsing  recto-vaginal  septum 
could  never  be  entirely  disposed  of  by  this  method,  for  a  more  or  less 
convex  vaginal  surface  would  always  remain  after  the  operation.     In 

the   diagram,  Fig.   66,  the    dotted   line 
o-      •  ^  ^  is  to  represent  the   portion  of  the 

^^- -^  h       ^/^^---^aC     posterior  vaginal  wall  which  was  brought 

\TV''---— J£j    up  behind  the   closed  perineum  by  the 

A'r -/ J     sutures  1,  2,  3,  4,  and  5,  while  the  dotted 

..\ 1  A     lines  C  and  D  mark  the  direction  of  the 

I  J     two    sutures   which   were    passed    only 

through  from  one  labium  to  the  other. 

The  result  of  this  operation  was  only  of 
■t»'\"\'     temporary   benefit,  a  triangular   hollow 

space  was  always  left  at  E^  just  behind 
the  new  perineum,  which  soon  became  filled  by  a  fold  from  above, 
and  this  portion  prolapsed  as  far  as  the  barrier  formed  by  the  labia 
would  permit.  But  so  soon  as  one  portion  came  down,  its  place  would 
be  at  once  occupied  by  the  tissue  just  behind  it,  so  that  the  column 
became  gradually  weakened.  The  perineum  became  overstretched, 
and  the  original  condition  of  rectocele  or  procidentia  was  in  time,  as 
a  rule,  gradually  reproduced.  The  convex  surface  remaining  on  the 
recto-vaginal  septum  after  this  operation  is  a  great  source  of  weakness. 
As  a  consequence  of  any  downward  pressure,  this  curve  becomes  in- 
creased, so  as  to  bring  the  full  force  to  bear  against  the  newly-formed 
perineum.  It  becomes  then  but  a  question  of  time  for  absorption  to 
take  place,  and  the  original  condition  to  be  reproduced. 

If,  with  a  tenaculum,  we  were   to  catch  up  a  portion  of  a  cloth 


PRINCIPLES    OF    THE    OPERATION.  389 

table  cover,  and  attempt  to  make  traction,  several  folds  would  be 
formed.  These  folds  -would  be  formed  on  each  side,  and  would  lead 
off  from  the  instrument  to  any  point  where  the  cover  might  be  secured 
along  the  edge  of  the  table,  or  to  where  a  certain  amount  of  friction 
had  to  be  overcome.  Now,  in  a  case  of  rectocele,  the  tissues  can  be 
caught  up  in  the  same  manner,  and  drawn  towards  the  vaginal  outlet. 
Unless  the  procidentia  has  been  complete,  so  that  the  integrity  of  the 
Avhole  posterior  wall  has  been  impaired,  the  amount  of  prolapse  can  be 
accurately  appreciated  by  this  method.  It  would,  of  course,  be  easy 
to  draw  down  the  whole  posterior  wall  by  exercising  a  sufficient 
amount  of  force,  but  we  must  not  go  so  far  as  that. 

The  crest  of  the  rectocele,  at  F^  Fig.  66,  represents  the  limit  of  the 
prolapse,  and  the  septum  above  that  point  possesses  yet  sufficient  in- 
tegrity to  remain  in  position  when  freed  from  the  drag  below.  This 
will  likely  be  the  case,  since  the  cellular  tissue  with  which  it  is  closely 
connected  has  not  yet  been  overstretched.  When  this  crest  is  thus 
drawn  down  to  the  vaginal  outlet,  we  are  able  to  trace  with  the  finger 
these  folds  extending  obliquely  into  the  sulcus  on  each  side,  and  we 
may  judge  by  the  yielding  of  the  tissues  as  to  the  extent  of  the  pro- 
lapse. As  we  make  this  traction  in  case  of  a  rectocele,  we  can 
satisfy  ourselves,  by  passing  up  the  finger  to  the  uterus,  that  the 
organ  is  not  involved. 

In  the  operation,  the  mucous  membrane  must  be  removed  from  over 
the  whole  surface,  extending  from  the  vaginal  outlet  to  the  crest  of 
the  rectocele.     The  uppermost  suture  C,  Fig.  67,  which  formerly  was 
made  to  include  only  the  tissues  of  the 
labia,  must  now  be  introduced  at  F, 
Fig.  66,  so  as  to  draw  down  that  por- 
tion, and  obliterate  the  open  space 
which  was  always  left  at  E.    After  all 
the  sutures  have  been  secured,  the  line 
of  union  A  B,  Fig.  67,  will  show  the 
direction  in  which  the  excess  of  tissue 
forming  the  rectocele  was  folded  in. 
The  eifect  has  been  to  change  entirely 
the  shape  of  the  vaginal  wall,  so  that 

as  the  finger  enters  the  canal  it  will  pass  at  once  along  a  concave 
surface.  By  this  operation,  the  vaginal  wall  will  have  been  restored 
to  its  original  shape  and  size,  with  a  firm  perineum  directly  supported 
by  the  fascia  and  connective  tissue  of  the  pelvis.  As  this  surface  is 
now  concave,  no  downward  force  can  be  exerted  against  the  perineum, 


390  LACERATION    OF    THE    PERINEUM. 

and  the  only  eifect  of  pressure  so  directed  would  be  to  increase  the 
concavity,  and  to  distribute  the  force  along  the  floor  of  the  pelvis. 
When  only  the  proper  amount  of  tissue  has  been  turned  in  by  the 
operation,  this  curved  line  may  be  compared  to  the  surface  of  the 
bank  of  earth  placed  by  an  engineer  on  the  upper  side  of  a  dam 
which  he  has  thrown  across  a  stream.  Without  this  protection,  if  a 
simple  wall  were  built,  the  whole  force  and  weight  of  the  volume  of 
water  would  be  concentrated  against  a  point  near  the  centre,  which 
would  first  bow  outwards,  or  bulge,  before  being  swept  away.  But, 
if  the  engineer  possesses  a  knowledge  of  the  volume  of  water,  which 
is  to  pass  in  a  given  time,  and  also  its  velocity,  he  will  so  shape  this 
bank  of  earth,  at  the  proper  angle,  that  the  force  of  the  stream  will 
be  distributed  equally  along  its  surface,  and  the  wall  will  be  protected. 

For  the  operation,  the  patient  is  to  be  placed  on  a  narrow  table, 
and  Avhile  lying  on  the  back,  with  the  legs  drawn  up,  the  ether  can 
be  administered.  But  before  commencing  the  operation,  the  night- 
dress and  flannel  must  be  drawn  up  to  the  waist,  so  that  they  may 
not  become  soiled.  In  the  region  of  the  coccyx,  it  will  be  necessary 
to  place  a  sponge  or  a  folded  towel  to  collect  the  blood  which  will 
run  down  between  the  buttocks.  Both  legs  must  now  be  flexed  on  the 
abdomen,  to  be  thus  held  by  an  assistant  after  the  body  of  the  patient 
has  been  drawn  down  to  the  edge  of  the  table.  One  assistant  must 
stand  facing  the  operator  on  each  side  of  the  table.  Such  a  position 
will  enable  each  assistant  to  secure  one  of  the  patient's  legs  by  pass- 
ing his  arm  over  the  limb  as  it  is  flexed.  This  will  leave  the  hands 
disengaged,  and  the  nearest  one  can  be  employed  to  keep  the  labium 
on  that  side  retracted.  In  separating  the  labia,  the  fingers  of  one 
assistant  must  be  placed  directly  opposite  those  of  the  other.  This 
is  necessary,  for  if  not  on  the  same  line,  or  if  unequal  traction  be 
made,  it  would  be  difficult  to  avoid  denuding  the  side  of  one  labium 
higher  than  that  of  the  other. 

We  may  commence  the  operation  by  removing  the  mucous  mem- 
brane from  any  point,  but  it  is  best  to  do  so  at  the  most  dependent 
portion.  We  then  advance  from  below  upwards,  and  thus  avoid  the 
flow  of  blood  over  the  surface  to  be  removed.  The  mucous  membrane 
is  caught  up  on  the  point  of  a  tenaculum,  and  M'ith  a  pair  of  properly 
curved  scissors,  it  should  be  removed  in  a  horizontal  strip  running 
from  side  to  side.  If  the  operator  is  ambidextrous  the  whole  surface 
may  be  removed  in  one  continuous  strip.  By  using  a  pair  of  scissors 
with  a  different  curve  to  turn  the  point  at  one  labium,  avc  can  extend 
the  line  back  again  upon   the    posterior  wall   of  the  vagina,  from 


DETAILS    OF    THE    OPERATION.  391 

there  to  the  opposite  labium,  and  then  over  the  same  course  a^nm 
just  above  the  preceding  one.  The  first  step  in  he  operation 
shouhi  be  to  determine,  by  the  method  already  described,  the  extent 
to  which  the  denudation  is  to  be  carried  on  the  posterior  wall.  This 
point  we  mark  by  removing,  as  a  guide,  a  small  portion  of  tissue  from 
the  median  line.  The  advantage  of  the  scissors  in  this  operation  can- 
not be  questioned.  With  the  utmost  dexterity  and  quickness,  the 
parts  cannot  be  freshened  and  brought  together  without  a  great  loss 
of  blood.  The  amount  of  bleeding  is  less  from  the  use  of  scissors, 
and  with  them  the  parts  can  be  denuded  in  a  much  shorter  time  than 
with  the  knife. 

I  always  use  a  thick,  straight  sewing  needle,  from  an  inch  and  a 
half  to  two  inches  in  length,  with  a  large  eye  for  introducing  the  silk 
loop  to  which  the  wire  is  to  be  afterwards  attached  before  being 
drawn  through.  I  adopted  the  use  of  the  straight  needle  after  having 
devoted  much  time  and  thought  in  attempting  to  perfect  some  better 
means.  If  the  curved  needle  with  a  handle,  which  is  now  in  common 
use,  be  used,  it  is  first  passed  through  the  tissues,  and  then  the  loop 
of  thread  is  introduced  into  the  eye  at  its  point,  and  pulled  through 
as  the  needle  is  withdrawn.  The  handle  gives  great  control  in  directing 
the  course  of  the  instrument,  so  that  it  is  readily  introduced.  I  have 
also  used  hollow  needles  of  different  curves,  having  a  handle,  and 
equally  well  under  control.  But  the  one  great  objection  to  all  of 
these  instruments  is  the  large  size  which  is  necessary  to  secure  for 
them  the  requisite  rigidity.  If  they  were  not  rigid  and  unbending, 
it  would  be  impossible,  even  with  the  aid  of  the  handle,  to  direct 
their  course  with  any  accuracy. 

The  tissues  through  which  these  instruments  are  to  be  introduced 
are  exceedingly  vascular,  so  that  a  thrombus  is  easily  formed,  and 
this  generally  terminates  in  an  abscess.  To  avoid  this  difficulty — 
which  is  not  a  theoretical  one — it  is  necessary  to  discard  any  instru- 
ment Avhich  has  its  point  terminating  in  a  flat  cutting  edge,  and  the  dia- 
meter of  the  instrument  should  be  reduced  as  much  as  possible,  so  that 
it  may  correspond  somewhat  closely  to  that  of  the  suture.  A  straight 
needle,  Avhich  acts  like  a  wedge,  and  has  its  widest  diameter  near  the 
eye,  will  alone  present  these  advantages.  The  passage  of  the  needle 
forms  a  canal  by  separating  the  tissues,  and  not  by  cutting  them,  so 
that  the  silver  wire  suture  when  introduced  will  fully  occupy  the 
opening.  A  needle  with  a  curve  near  the  point  would  possess  some 
advantages  at  its  exit  from  the  tissues,  but  a  curved  needle  will  roll 
in  the  grasp  of  the  forceps,  so  that  its  course  cannot  be  directed  with 


392  LACERATION    OF    THE    PERINEUM. 

any  certainty,  and  in  order  to  secure  the  necessary  strength  it  must 
he  made  greater  in  diameter  than  if  it  were  straight. 

The  introduction  of  a  straight  needle  through  a  semicircular  course 
may  seem  difficult,  but  such  is  not  the  case,  as  the  soft  parts  are  so 
yielding.  The  index  finger  must  be  passed  into  the  rectum  to  appre- 
ciate the  course  and  facilitate  the  passage  of  the  needle,  and,  at  the 
same  time,  it  will  protect  the  posterior  wall  of  the  bowel  from  becoming 
transfixed.  As  the  tissues  of  the  recto- vaginal  septum  are  thus  lifted 
up  on  the  point  of  the  finger  the  course  to  be  followed  by  the  needle 
becomes  nearly  straight.  If  we  introduce  the  needle  into  the  left 
labium  it  is  made  to  sweep  in  a  curved  line,  with  its  point  to  the  right, 
by  pressing  the  jaws  of  the  forceps  into  the  soft  parts  just  in  proportion 
as  the  needle  is  advanced  in  its  course.  Then,  when  the  median  line 
has  been  passed  by  the  point  of  the  needle,  its  course  is  directed  to- 
Avards  the  point  of  exit  by  gradually  rotating  the  hand  to  the  left.  As 
the  point  of  the  needle  approaches  the  skin  its  exit  can  be  directed,  and 
the  necessary  counter-pi-essure  be  made  by  the  thumb-nail  alongside 
of  the  finger  in  the  rectum.  As  soon  as  the  point  of  the  needle  has 
been  sufiiciently  cleared,  by  pressing  back  the  tissues  with  the  nail, 
it  can  be  seized  by  the  forceps  and  drawn  through.  The  only  special 
dexterity  required  in  the  passage  of  the  needle  is  to  properly  rotate 
the  forceps  and  wrist  until  the  course  of  the  point  can  be  directed  by 
the  thumb-nail.  The  natural  impulse  is  to  overcome  the  resistance  of 
the  tissues,  and  to  sweep  the  needle  through  the  curved  course  by 
twisting  it  in  the  grasp  of  the  forceps.  The  consequence  is  that  the 
needle  is  usually  broken  just  beyond  the  grasp  of  the  forceps,  and  the 
portion  already  imbedded  is  often  extracted  with  great  difficulty. 
The  plan  is  a  good  one  to  introduce  the  wire  as  soon  as  the  loop  of 
thread  has  been  drawn  through,  since  the  oozing  will  occasionally  be 
troublesome  if  we  allow  the  silk  to  remain  in  the  tissues  for  some  time 
and  then  disturb  it. 

We  may  now  briefly  review  the  steps  of  the  operation,  by  reference 
to  the  accompanying  Fig.  68.  The  letter  C  is  placed  at  the  crest 
of  the  rectocele,  in  the  same  position  as  represented  in  the  tAvo 
preceding  diagrams.  It  is  shown  that  the  surface  has  been  de- 
nuded from  the  edge  of  the  sphincter  ani  muscle  up  each  labium  to 
the  remains  of  the  carunculae,  and  across  on  the  posterior  wall  of  the 
vasina  to  the  extent  of  the  rectocele.  Suture  1  Avas  introduced 
nearest  to  the  edge  of  the  anus,  and  its  course  through  the  recto- 
vaginal septum  is  indicated  by  the  dotted  line.  The  same  explanation 
in  regard  to  their  course  is  applicable  to  the  other  numbered  sutures. 


INTRODUCTION  OF  THE  SUTURES. 


393 


The  course  of  the  suture  D  is  shown  on  its  exit  from  behind  one 
labium  to  enter  at  D  on  the  upper  edge  of  the  denuded  surface  over 
the  posterior  -wall  of  the  vagina.  This  is  essentially  the  last  suture 
introduced  to  secure  this  surface,  and  does  not  include  more  than  an 


Operation  for  lacerated  perineum. 

inch  before  it  passes  to  the  opposite  labium.  The  course  of  the  upper- 
most suture  C  is  through  the  labium  just  in  line  with  the  limit  of  the 
freshened  surface.  It  is  then  made  to  catch  up  a  small  portion  of  the 
vaginal  tissue  at  C,  beyond  the  denuded  surface  on  the  recto- vaginal 
wall,  when  it  also  passes  to  the  opposite  labium.  Experience  has 
demonstrated  the  advantage  of  going  beyond  the  line,  and  of  not  in- 
cluding more  tissue.  Formerly,  when  this  suture  was  introduced  at 
D,  along  the  upper  edge  of  the  denuded  surface,  and  the  parts  were 
then  brought  together,  the  union  was  seldom  complete.  The  edges 
were  frequently  pulled  apart  on  carelessly  introducing  the  catheter, 
from  movement  of  the  limbs,  or  from  a  certain  amount  of  dras^ins; 
backward  from  the  weight  of  the  posterior  wall  of  the  vagina.  .  It 
was  difficult  also  to  protect  the  parts  from  urine,  Avhich  would  some- 
times force  its  way  in  behind  the  flaps  and  prevent  union.  It  is, 
therefore,  intended  that  this  suture  should  draw  a  portion  of  the 
vaginal  tissue  sufficiently  forward  to  protect  the  edges,  which  have 
been  approximated  by  the  preceding  suture.  At  the  same  time  this 
suture  plays   even  a  more  important  part,  since,  by  including  the 


394 


LACERATION    OF    THE    PERINEUM. 


tissue  beyond,  it  sustains  all  the  traction  until  the  denuded  surfaces 
have  had  time  to  become  firmly  united. 

The  labia  being  convex  surfaces  it  is  not  possible  to  give  by  a  dia- 
gram the  extent  of  tissue  fashioned  on  their  posterior  face.  The  out- 
line of  the  surface  denuded  for  this  operation  may  be  compared  to  the 
figure  of  a  trefoil.     The  cusps  A  and  B,  Fig,  69,  are  supposed  to  rep- 


resent the  labia,  the  surfaces  of  which  are  divided,  2  2  being  the  pos- 
terior or  vaginal  side,  and  C  would  be  the  denuded  portion  on  the 
recto-vaginal  septum.  When  these  parts  are  secured  by  suture,  the 
points  A,  B,  and  C  come  together  along  the  line  dividing  each  section. 
The  surfaces  come  then  in  apposition  as  they  are  numbered,  1  and  1 
will  represent  the  thickness  of  the  labia,  2  and  3  the  posterior  portions 
united  to  corresponding  surfaces  on  the  recto-vaginal  septum.  This 
diagram,  Fig,  70,  represents  the  parts  just 
as  they  are  being  brought  up  into  contact, 
and  may  demonstrate  in  a  clear  manner  the 
condition,  A  B  and  C  are  the  points  brought 
together,  the  figures  11,2  2,  and  3  3  cor- 
respond in  position  to  same  given  in  the  preceding  diagram,  A  1 
and  B  1  show  the  thickness  of  the  labia,  and  2  C  3  the  fold  of  the 
rectocele,  drawn  up  behind  the  barrier,  like  a  bank  of  earth  behind 
the  mill-dam  as  has  been  described, 

I  have  never  found  any  necessity  for  using  more  than  the  one  set 
of  sutures,  which  should  be  passed  deep  to  include  a  liberal  amount  of 
tissue.  If  these  are  properly  introduced,  and  at  regular  intervals, 
superficial  sutures  will  be  superfluous.  It  is  advantageous  to  have  the 
silver  wire  for  this  operation  a  size  or  two  larger  than  that  in  general 
use,  since  it  gives  a  certain  amount  of  support  to  the  parts,  I  leave 
each  twisted  suture  about  three  inches  in  length,  and  when  the  opera- 
tion has  been  completed,  I  secure  the  ends  of  all  of  these  together, 


AFTER    TREATMENT.  395 

like  the  radii  of  an  open  fan.  These  ends  may  be  bound  together  by 
slipping  over  them  a  short  section  of  rubber  tubing  (see  Fig.  67), 
and  then  bending  back  the  end  of  one  of  the  sutures  to  keep  it  in 
place,  or  they  may  be  trapped  by  a  short  piece  of  wire  with  a  little 


Method  of  secnriug  the  ends  of  the  sutures. 

cotton  over  the  ends.     There  is  less  risk  of  labial  abscesses  or  acci- 
dental irritation  of  any  individual  suture  by  adopting  this  plan. 

After  Treatment. — The  patient  must  be  kept  n  bed  with  her  knees 
tied  together  and  a  soft  pad  between  them.  The  urine  should  be 
drawn  with  care,  to  prevent  it  from  running  over  the  healing  surfaces. 
This  can  best  be  done  by  flexing  the  legs  over  the  abdomen,  as  at  the 
time  of  the  operation,  but  without  removing  the  bandage  from  the 
knees.  Then,  with  a  strip  of  soft  cloth  covering  the  index  finger  of 
the  left  hand,  the  parts  may  be  protected  by  placing  this  beneath  the 
urethra  as  the  catheter  is  withdrawn.  The  additional  precaution 
should  also  be  taken  to  close  the  end  of  the  instrument  by  keeping 
the  finger  over  it.  A  difference  of  opinion  exists  as  to  the  necessity 
for  using  the  catheter,  and  in  regard  to  the  deleterious  effects  from 
urine  running  over  healing  surfaces.  I  have  been  most  anxious  to 
dispense  with  the  use  of  the  catheter  if  possible,  since  this  would  be 
a  great  desideratum,  but  I  have  certainly  gotten  the  best  results  when 
I  have  employed  it ;  so  that  notwithstanding  all  the  disadvantages  I 
must  advocate  its  use  whenever  it  is  practicable.  The  mere  passage 
of  fresh  urine  over  a  wound  is  not  in  itself  a  source  of  irritation,  but 
it  becomes  so  when  stale,  and  when  its  salts  are  deposited  on  the  heal- 
ing surface.  If  the  parts  could  be  properly  cleansed  after  the  urine 
had  been  passed  into  a  bed-pan,  the  use  of  the  catheter  might  be  dis- 
pensed with.     But  we  cannot  prevent  a  certain  amount  of  urine  from 


396  LACERATIOX    OF    THE    PERnSTEUM. 

passing  back  into  the  vagina,  and  it  is  even  likely  to  find  its  way 
between  the  tissues  which  have  been  brought  together.  But  should 
the  urethra  become  irritable,  or  circumstances  occur  in  which  the 
catheter  cannot  be  employed,  it  will  be  necessary  to  observe  more 
than  the  usual  cleanliness.  After  the  bladder  has  been  emptied,  and 
before  removing  the  bed-pan,  the  nurse  must  throw  a  pint  or  more  of 
tepid  water  into  the  vagina.  The  nozzle  of  the  syringe  should  be 
carefully  introduced  close  to  the  urethra,  and  during  the  administra- 
tion of  the  injection,  it  is  to  be  held  in  this  position  so  as  not  to  come 
in  contact  with  the  line  of  union.  The  parts  can  be  greatly  protected 
by  the  liberal  use  of  vaseline,  or  some  simple  ointment  of  the  proper 
consistency  to  remain  on  the  surface.  This  may  be  applied  for  pro- 
tection not  only  over  the  labia,  but  along  the  line  of  union,  and  in  the 
vagina,  which  is  the  part  most  exposed  to  the  action  of  the  urine. 
The  free  application  of  the  vaseline  or  cold  cream  over  the  labia  will 
add  greatly  to  the  comfort  of  the  patient  by  lowering  the  temperature 
of  the  parts,  and  it  should  be  used  even  if  not  needed  to  protect  them. 
As  the  bowels  can  be  moved  without  materially  disturbing  the  line  of 
union,  nature  may  be  allowed  to  take  its  course  if  the  demand  be 
made,  but  the  diet  had  better  be  regulated,  if  possible,  to  constipate 
the  bowels  for  five  or  six  days.  Opium  should  not  be  used  in  any 
form,  unless  the  necessity  be  very  great,  and  even  then  it  is  well  to 
seek  some  substitute  for  it.  The  position  of  the  patient  may  be 
changed  from  the  back  to  either  side  without  injury  to  the  sutures,  so 
long  as  the  limbs  are  kept  together.  I  direct  the  patient,  beforehand, 
to  draw  the  limbs  well  up,  and  then  have  her  rolled  over  on  to  the 
side  by  lifting  up  the  mattress  with  the  hands  separated,  grasping  it 
with  one  hand  at  the  level  of  the  shoulder,  and  with  the  other  at  the 
hips.  By  this  simple  plan  a  patient  can  be  moved  with  very  little 
disturbance.  If  it  be  wished  to  change  the  position  without  turning 
her  completely  on  the  side,  a  bolster  or  several  pillows  may  be  placed 
under  the  mattress,  so  as  to  support  the  body  of  the  patient  at  any 
angle.  The  parts  will  have  become  sufficiently  healed  by  the  seventh 
day  for  the  removal  of  the  sutures.  No  advantage  is  to  be  gained  by 
leaving  them  for  a  longer  time,  but,  on  the  contrary,  there  will  be 
risk  from  inflammation  following  some  accidental  injury.  To  remove 
the  sutures,  it  will  be  necessary  to  place  the  patient  on  a  table,  and 
on  her  back,  with  the  feet  drawn  up.  As  it  would  not  be  advisable 
to  separate  the  parts  to  bring  the  loops  into  view,  it  will  be  necessary 
to  trust  somewhat  to  the  sense  of  touch.  We  are  first  to  remove  the 
piece  of  tubing  by  cutting  through  the  mass  of  sutures,  which  will 


LACERATION  OF  THE  SPHINCTER  ANI.         397 

free  their  ends.  Then  the  loAvest  one  may  be  grasped  by  a  pair  of 
forceps  and  gently  turned  to  the  right  side,  while  the  blades  of  a  pair 
of  sharp  pointed  scissors  are  passed  down  along  the  left  side  of  the 
suture  in  search  of  the  loop.  AVe  endeavor  to  get  the  loop  between 
the  points  of  the  scissors,  close  to  the  twisted  portion,  and  we  can 
generally  feel  certain  Avhen  this  portion  is  within  grasp.  It  is  im- 
portant to  possess  this  knowledge,  since  it  is  an  awkward  accident  to 
cut  the  twisted  portion  aAvay,  leaving  the  loop  imbedded  in  the  tissues, 
to  cause  much  irritation  and  annoyance  afterwards.  We  cannot 
always  be  certain  that  we  have  only  caught  up  the  loop,  but,  as  a 
rule,  when  the  points  of  the  scissors  are  gently  closed,  we  are  able  to 
appreciate,  by  the  degree  of  resistance,  between  the  single  strand  of 
wire  and  the  twisted  portion  of  double  thickness.  When  the  loop  has 
been  cut,  the  suture  must  be  withdrawn  from  the  tissues  in  a  manner 
to  cause  as  little  irritation  as  possible,  and  without  pulling  apart  the 
recently  united  surfaces.  The  suture  must  be  drawn  out  across  the 
labium  to  the  same  side  on  which  the  loop  has  been  cut,  and  by  doing 
so,  each  portion  of  the  wire  will  continue  to  bind  the  parts  together 
until  its  exit.  The  parts  can  be  supported  and  also  protected  by  an 
assistant  pressing  or  holding  the  labia  together  until  all  the  sutures 
have  been  withdrawn.  For  a  week  after  the  removal  of  the  sutures, 
the  limbs  should  remain  bound  together,  then  the  bandage  may  be 
thrown  aside,,  and  only  used  at  night  for  a  short  time  longer.  It 
should  be  the  rule  that  the  patient  be  not  allowed  to  assume  the  up- 
right position  for  two  weeks,  and,  if  the  general  health  is  not  likely 
to  suffer  in  consequence  of  a  continued  confinement,  the  additional 
rest  of  another  week  will  be  of  advantage. 

As  the  patient  gradually  returns  to  her  every  day  life,  her  condition 
must  be  closely  w^atched.  On  detecting  the  slightest  tendency  to 
retroversion,  the  position  of  the  uterus  must  be  corrected,  and  a 
pessary  fitted  to  correspond  to  the  altered  condition  of  the  vagina. 
If  this  precaution  be  neglected,  and  the  uterus  become  retroverted, 
it  will  simply  be  a  question  of  time  before  all  will  be  lost  and  the 
original  condition  be  reproduced. 

Laceration  through  the  Sphincter  Ani,  and  the  Mode  of  Operatinfi 
for  its  Relief. — This  subject  naturally  follows  in  connection  with 
laceration  of  the  perineum,  since  it  is  but  an  extension  of  the  same 
injury.  It  is,  however,  without  any  necessary  bearing  on  the  study  of 
procidentia,  since  advice  is  generally  sought  for  early,  and  the  injury 
repaired  before  sufficient  time  has  elapsed  for  the  case  to  become  thus 
complicated.     Both  conditions  are  but  different  degrees  of  the  same 


398  LACERATION    OF    THE    PERINEUM. 

injury,  and  the  same  operation  also,  varying  only  in  detail,  is  required 
for  the  relief  of  both.  Therefore,  even  if  the  connection  of  a  common 
cause  did  not  exist,  it  would  be  essential  to  consider  the  modes  of 
treatment  together  in  order  to  avoid  repetition. 

Etiology. — In  the  accompanying  Table  XXXII,  the  record  is 
given  of  fifty-three  cases  of  complete  laceration  through  the  sphincter 
ani.  These  were  treated  in  my  private  hospital,  but  constitute  only 
a  part  of  the  total,  as  there  were  other  cases  of  which  the  records 
were  so  incomplete,  that  they  could  not  be  utilized. 

The  first  feature  presented  by  the  table  is  the  early  age  of  those 
who  had  sustained  this  injury  several  years  before  applying  for  relief. 
This  fact  is  of  more  particular  interest  in  comparison  with  the  average 
age  of  those  who  suffered  from  the  different  stages  of  procidentia. 

The  average  age  of  puberty  is  essentially  the  same  as  that  found 
to  be  the  general  average  for  the  women  of  the  better  classes. 

The  time  of  marriage  is  fully  two  years  later  than  the  average  for 
those  who  suffered  from  cystocele  or  complete  procidentia,  while  it 
is  almost  the  same  as  that  found  for  those  with  rectocele,  who  were 
treated  in  my  private  hospital.  The  average  age  at  the  time  of 
marriage  being  also  so  much  beyond  the  general  average  on  all 
women,  it  is  but  natural  to  infer  that  this  injury  has  some  connection 
with  marriage  contracted  late  in  life.  Yet,  on  the  other  hand,  but 
thirty-two  per  cent,  o  the  total  number,  who  suffered  from  laceration 
through  the  sphincter  muscle,  were  found  to  have  married  after  the 
age  of  twenty-five  years. 

The  number  of  children  borne  by  those  who  suffered  from  this  in- 
jury, is  about  half  the  number  credited  to  those  who  had  procidentia 
in  after  life,  and  the  proportion  is  about  the  same  if  made  before  the 
operation,  or  if  taken  on  the  total  number. 

The  average  length  of  time  since  the  reception  of  the  injury,  and 
that  since  the  birth  of  the  last  child,  is  much  less  than  was  the  case 
with  procidentia.  Yet,  the  condition,  as  would  naturally  be  supposed, 
does  not  seem  to  have  been  so  great  a  bar  to  impregnation  as  the  dif- 
ferent stages  of  prolapse.  The  average  age  at  the  time  of  receiving 
the  injury  was  twenty-seven  years,  being  just  five  years  less  than  the 
average  for  those  who  suffered  from  procidentia  in  its  different  stages. 
The  proportion  who  were  injured  in  their  first  labor  was  77.35  percent. 

In  regard  to  the  method  of  delivering,  thirty-three  cases,  or  62.11 
per  cent,  were  delivered  by  means  of  the  forceps.  This  proportion 
was  taken  on  the  total  number  which  included  four  cases  when  the 
condition  of  labor  was  not  given.     The  proportion  of  unusually  large 


ETIOLOGY. 


399 


^ 


^ 


5:^ 


-a 

•neJpiinD  93aB7 

n 

a 

is 
o 

0 

0 
u 

0 

=3 

d 

0 

■sQiAiX 

Cl 

•iCnioioin'BJO 

" 

•Sntnjnx 

CI 

'sdsaioj 

g 

•snoipox 

-f 

•ptdTja 

:^ 

•pajiJis  lo.sj 

oc 

•poAiaooJ  SUM.  /jnfni 

•j^jtifni  JO  oral}  oqj  ?T3  sSy 

27.01 

Change  of 
lile. 

•siBajC  ni  eStiJoA-B 
pn-E  sqjHoni  m  snii.X 

0 

■93v  puB  jaqmuy: 

0 

•jfouunSoaJ  jstix 
oonis  i)°vi3\v  puB 
sjTjjji  JO  Jtaqmun  I'BJOx 

0        2 

•.ijTlfnT  9T13  SnTAT9Daj 

eonis  euiij  jo  q^Snai 

n      0 

1 
0 

cj 
0 

p 

0 

u 
to 

a 

•nsjpiiTio  JO  jaqinnn 
eSrJ3Aii  pnE  f-gion-RU 
-Said  ;o.io'tninn  pjox 

-    ?; 

< 

•seS-BpjBDSiK 

CO 

•UOipiTTIO 

2 
.0 

■SaS'BllJ'BDSII^ 

il 

■nsjpiiqo 

0       ^• 

Ago  at  tho  timo  of 

•oS-c^jj-BK 

M 

•jCjjsqn,! 

44 
14.1S 

•noissttnpv 

in 

CO 

1 

"S. 

.2  a 

>• 

400  LACERATION    OF    THE    PERINEUM. 

children  was  more  than  usual,  and  in  every  instance  they  were  de- 
livered by  forceps.  Craniotomy  was  performed  in  one  instance,  when 
the  pelvis  was  very  much  contracted.  Eighteen  cases  only  of  lacera- 
tion of  the  cervix  were  noted,  a  number,  I  am  satisfied,  which  future 
observation  will  show  to  be  below  the  usual  proportion. 

Operation. — During  the  autumn  of  1862,  and  in  the  following  year, 
I  investigated  the  use  of  the  rectal  tube.  This  instrument  which  was 
about  equal  in  size  to  a  No.  12  bougie,  had  been  employed  by  Dr. 
Sims  with  the  view  of  allowing  free  vent  to  the  escape  of  flatus. 
Whenever  the  operation  failed,  leaving  a  recto-vaginal  opening  just 
behind  the  sphincter  ani,  it  was  generally  attributed  to  stoppage  of 
the  tube  from  feces,  while  occasionally,  it  was  suspected  that  the 
nurse,  through  carelessness,  would  force  the  tube  into  the  vagina  be- 
tween the  sutures.  As  I  made  myself  familiar  with  the  details,  1 
became  the  more  skeptical  as  to  the  necessity  for  the  rectal  tube, 
since  it  was  almost  impossible  ever  to  keep  it  free.  I  began  my  ex- 
periments by  substituting  a  short  section  of  a  solid  rod  the  size  of  the 
tube.  This  was  tied  in  and  allowed  to  remain  undisturbed  for  several 
days  ;  the  operation  proved  a  success.  I  increased  the  size  of  the 
plug  and  succeeded  in  several  more  cases,  but  as  the  diameter  exceeded 
that  of  the  little  finger,  irritation  Avas  excited,  and  the  operation 
failed.  I  next  used  a  section  of  a  copper  sound,  which  was  somewhat 
less  than  half  the  diameter  of  the  original  rectal  tube.  This  small 
foreign  body  proved  a  great  source  of  irritation,  and  the  operation 
failed.  For  several  years  I  was  at  a  loss  for  an  explanation,  beyond 
the  supposition  that  the  tube  relaxed  the  sphincter,  yet,  experience 
soon  taught,  as  I  have  stated,  that  there  was  a  limit  beyond  which 
any  increase  in  size  caused  irritation.  I  concluded  to  use  neither 
tube  nor  plug,  and  continued  to  operate  until  about  the  beginning  of 
1870  with  varied  success,  unable,  however,  to  offer  an  explanation  for 
the  success  at  one  time,  and  failure  at  another.  In  a  large  immber 
of  cases,  not  a  fibre  of  the  muscle  was  united,  althougli  the  perineum 
may  have  been  restored,  and  the  laceration  through  the  recto- vaginal 
septum  closed  by  the  operation.  To  unravel  the  cause  of  failure,  and 
to  devise  the  means  of  obviating  it,  occupied *my  attention  for  years. 
To  appreciate  so  simple  a  condition,  as  I  shall  explain,  cost  me  more 
thought  than  I  have  ever  devoted  to  any  other  professional  subject. 
Early  in  1873,  I  published^  an  account  of  the  cause  of  failure,  and 

'  Laceration  of  the  Perineuni,  involving  the  Sphincter  Ani,  an  operation  for 
securing  Union  of  the  Muscle.     N.  Y.  Medical  Record,  March  15,  1873. 


author's  mode  of  operatino.  401 

a  new  mode  of  operation,  and  I  have  now  but  little  to  add  as  the 
result  of  further  experience. 

When  the  perineum  and  the  muscular  ring  forming  the  sphincter 
ani  have  been  lacerated,  a  gaping  triangular  opening  is  left.  The 
base  of  this  opening  is  formed  by  the  lacerated  muscle,  and  the  apex 
by  the  limit  of  the  laceration  through  the  recto-vaginal  septum.  For 
the  convenience  of  demonstration  we  win  describe  the  shape  of  the 
divided  muscle.  Gradually  the  fibres  which  formed  the  inner  surface 
of  the  circle,  when  the  muscle  Avas  in  its  integrity,  will  have  shortened 
more  than  those  on  the  outer  margin  which  remain  attached  to  the 
neighboring  tissues,  because  muscular  fibres  always  retract  when  they 
have  been  freed  from  their  attachments.  A  glance  at  the  diagram. 
Fig.  72,  will  show  the  corners  of  the  muscle  rounded  off,  and  that 

Fig.  72. 


Diagram  of  ruptured  sphincter  ani. 

the  muscular  fibres  nearest  the  mucous  membrane  of  the  rectum  have 
contracted  more  than  the  others.  A  convex  surface  is  thus  presented 
by  the  shortening  of  the  inner  fibres,  and  the  muscle  no  longer  re- 
sembles a  parallelogram,  which  was  the  original  shape  just  after  it  was 
ruptured.  This  shortening  of  the  fibres  of  the  muscle  has  hitherto 
been  entirely  overlooked,  and  to  this  cause  must  we  attribute  the 
failure  to  re-establish  control  over  the  escape  of  flatus  and  the  con- 
tents of  the  bowels  when  in  a  fluid  state.  This  must  be  the  result 
if  the  operator  only  extends  the  denuded  surface  from  above  to  A  B, 
the  apparent  limit  of  the  laceration,  since  but  a  small  portion  of  the 
ends  of  the  muscle  can  ever  thus  be  brought  in  contact. 

After  the  edges  of  the  muscle  have  been  properly  freshened,  the 
most  important  step  in  the  operation  will  be  the  introduction  of  the 
first  suture  in  its  proper  relation  to  the  edges  of  the  divided  muscle. 
If  the  first  suture  be  entered  on  the  line  a  little  outside  of  A  B,  Fig. 
72,  and  at  the  point  which  would  seem  the  most  appropriate,  only  a 
small  portion  of  the  muscle  will  be  approximated.  Fig.  73  exhibits  the 
26 


402 


LACERATION    OF    THE    PERINEUM. 


condition  of  the  parts  when  they  have  been  thus  secured  by  a  suture 
entered  from  A  B,  and  shows  that  the  retentive  power  is  not  re-estab- 
lished. Introduce,  however,  the  suture  at  some  distance  behind  the 
edge  of  the  muscle  at  the  points  C  D,  Fig,  72,  and  a  different  result  will 


Fig.  73. 


Fis.  74. 


Faulty  introduction  of  suture. 


Pi'opev  introduction  of  sutures. 


be  obtained.  A  glance  at  Fig.  74  will  show  that  on  securing  the  sutures 
the  divided  edges  of  the  sphincter  will  be  turned  up  and  brought  in 
perfect  apposition.  When  the  suture  is  passed  from  behind  the  edges 
of  the  muscle  and  around  the  laceration  in  the  recto-vaginal  septum, 
the  edges  of  the  muscle  will  be  turned  up  on  tightening  it.  As  this 
suture  runs  backward,  obliquely  across  the  rectal  extremity,  it  seems 
at  first  glance  as  if  it  were  impossible  that  it  could  be  secured  without 
shutting  up  the  anu3.  This,  however,  is  not  the  case,  for  the  ends 
of  the  muscle  are  drawn  upward  on  tightening  the  suture,  when 
passed  above  through  the  recto- vaginal  septum,  which,  to  a  certain 
extent,  is  a  fixed  point.  The  actual  position  of  this  suture  Avhen  twisted 
is  shown  by  Fig.  74  to  be  above  the  anus.  As  the  rectum  turns 
immediately  backward  into  the  hollow  of  the  sacrum,  the  outlet  is  in 
no  manner  encroached  upon.  When  this  suture  is  secured,  its  tendency 
is  to  roll  upward  and  outward  the  tissues  from  the  rectum  towards 
the  vagina.  One  effect  of  this  is  of  necessity  to  bring  in  contact, 
below  the  edge  of  the  laceration  and  throughout  its  course,  a  portion 
of  undenuded  mucous  membrane  of  the  rectum.  This  suture,  there- 
fore, along  the  rectal  portion  acts  as  a  safeguard  in  relieving  the 
second  suture  from  tension.  It  is  also  a  protection  against  the  ten- 
dency of  flatus  to  force  a  passage  into  the  vagina.  In  my  previous 
operations  this  second  suture,  passed  on  the  same  plane  with  the  edge 
of  the  laceration  through  the  rectum,  was  the  first  and  mainstay.  I 
then  frequently  noted,  as  the  other  sutures  above  were  secured,  that 
the  tissues  were  forced  downward.     The  efl'cct  of  this  was  to  spring 


author's  operation.  403 

apart,  as  it  were,  the  loop  of  this  first  suture,  and  then  a  large  portion 
of  denuded  tissue  became  rolled  out  into  the  rectum.  This  was  the 
cause  of  the  frecjuent  occurrence  of  a  small  recto-vaginal  fistula  at  the 
thinnest  point  in  the  septum.  This  opening  was  generally  situated 
just  behind  the  sphincter,  and  w^as  difficult  to  close  on  account  of  the 
constant  action  of  the  muscle. 

The  beneficial  effect  of  the  rectal  tube,  or  of  any  other  rounded 
body  left  in  the  anus,  when  the  size  of  the  instrument  is  not  sufficient 
to  act  as  a  source  of  irritation,  is  now  made  clear.  When,  by  accident, 
it  so  happened  that  the  retracted  fibres  of  the  sphincter  ani  muscle 
were  denuded,  the  presence  of  the  rounded  body  aided  greatly  in  the 
success  of  the  operation.  It,  of  course,  could  be  tolerated  in  the  anus 
only  so  long  as  the  muscle  was  relaxed.  Its  action  was  to  turn  up 
the  freshened  edges,  since  it  occupied  a  certain  amount  of  space,  and 
thus  aided  the  sutures  above  in  keeping  these  surfaces  in  contact. 
When  the  fibres  were  not  denuded,  no  union  of  the  muscle  could  take 
place,  although  the  septum  and  perineum  might  readily  unite. 

The  necessary  position  of  the  patient  for  the  operation,  with  all 
other  details,  are  essentially  the  same  as  described  for  closing  a  lace- 
ration of  the  perineum.  The  surfaces  which  have  been  lacerated,  and 
are  again  to  be  freshened,  are  generally  well  mapped  out  by  a  slight 
cicatricial  glaze.  Under  ordinary  circumstances,  unless  sloughing  has 
occurred,  there  can  be  but  little  difficulty  in  determining  the  extent. 
As  the  edges  of  the  laceration  through  the  septum  have  to  be  fresh- 
ened with  care,  it  is  essential  to  commence  the  denuding  from  the 
most  depending  point,  and  by  this  means  escape  the  annoyance  of 
blood  flowing  over  the  parts. 

If  we  examine  carefully  the  extremities  of  the  lacerated  muscle, 
we  will  find  a  slight  pit,  or  depression,  at  each  end,  which  has  been 
caused  by  the  contraction  of  a  portion  of  its  fibres.  It  is  necessary 
to  freshen  these  surfaces,  for  by  so  doing  we  denude  the  ends  of  the 
muscle  along  the  spaces  between  the  dotted  angles,  shown  in  Fig.  72. 
At  the  commencement  of  the  operation,  a  portion  of  the  tissues  at  one 
of  these  points  must  be  seized  with  a  tenaculum,  and,  with  a  pair  of 
scissors,  removed  together  with  a  narrow  strip  entirely  around  the 
laceration  to  the  opposite  end  of  the  muscle.  This  strip  must  be 
removed  as  close  to  the  edge  of  the  rectal  mucous  membrane  as  can 
be  done  without  wounding  it.  Whenever  the  edges  of  the  laceration 
in  the  recto-vaginal  septum  are  found  terminating  in  a  thin  bevelled 
edge,  it  will  be  necessary  to  gain  the  needed  width  by  removing  a 
sufficient  portion  of  the  vaginal  mucous  membrane. 


404  LACEEATIOX    OF    THE    PERINEUM. 

Occasionally,  the  laceration  through  the  recto-vaginal  septum  is 
found  to  terminate  in  a  double  cleft,  one  being  much  longer  than  the 
other.  In  this  condition,  success  would  be  doubtful  were  we  to  con- 
fine ourselves  only  to  the  thickness  of  the  walls  of  the  laceration. 
Therefore,  in  addition,  I  alwaj^s  remove  a  suflBcient  portion  from  the 
vaginal  surface  beyond  to  include  both  fissures,  and  also,  by  way  of 
compensation,  in  the  opposite  direction  from  these,  so  that  when  the 
edges  of  the  freshened  surfaces  are  brought  together,  they  will  meet 
in  the  median  line  as  if  a  simple  laceration  had  occurred. 

The  needle  is  to  be  introduced  behind  the  edge  of  Uie  muscle  to  the 
left,  at  the  point  D,  Fig.  72.  It  is  then  made  to  sweep  around  the 
angle  of  the  laceration  in  the  septum  to  the  point  of  exit  at  C,  and 
this  is  done  by  gradually  rotating  the  forceps  with  a  movement  of  the 
wrist.  As  in  laceration  of  the  perineum,  it  is  necessary  that  the 
index  finger  of  the  left  hand  be  introduced  into  the  rectum  to  serve 
as  a  guide.  As  the  point  of  the  needle  punctures  the  skin  in  its  exit, 
the  finger  may  be  withdrawn  from  the  rectum  to  aid  the  passage  of 
the  needle.  This  can  be  done  by  the  counter  pressure  of  a  blunt 
hook,  or  by  sliding  back  the  tissues  sufficiently  with  the  fingers,  for 
the  needle  to  be  seized  by  the  forceps  and  drawn  through.  The 
second  suture  is  to  be  introduced  just  outside  of  the  end  of  the  muscle, 
and  in  the  same  plane  with  the  divided  rectal  edge  of  the  laceration. 
The  third  suture  is  to  secure  the  vaginal  edge  of  the  laceration.  It 
should  be  made  to  include  the  tissues  liberally,  and  to  sweep  around 
the  angle  of  the  laceration  at  some  distance  beyond  the  course  of  the 
first  and  second  suture.  This  is  necessary  because  this  suture  is  the 
one  most  liable  to  cut  through  the  recto-vaginal  septum  and  leave  a 
fistula.  The  other  sutures  are  to  be  introduced  as  in  a  case  of  simple 
laceration  of  the  perineum. 

It  is  necessary  to  secure  first  the  lowest  suture  C,  D.  This  is 
done  by  seizing  the  ends  of  the  Avire  at  a  proper  distance,  so  that  the 
index  fingers  may  be  used  to  slide  the  tissues  firmly  down  on  the 
suture,  as  moderate  traction  on  the  wire  is  made  at  the  same  time 
with  the  hands.  The  suture  is  then  secured  without  relaxing  the 
traction,  by  several  half  turns  made  on  reversing  the  position  of  the 
hands  from  one  side  to  the  other.  Each  suture  is  thus  in  turn  secured 
from  below  upward.  Experience  can  alone  indicate  the  proper 
amount  of  tension  to  be  made,  and  success  will  depend,  to  a  great 
degree,  upon  this  manoeuvre.  The  parts  should  be  just  brought  in 
apposition,  and  no  more,  for  in  a  few  hours  there  will  be  sufficient 
swelling  to  force  the  tissues  in  close  contact.     If  the  sutures  have 


author's  operation.  405 

been  twisted  too  tightly,  and  especially  if  they  have  been  introduced  in 
too  superficial  a  manner,  they  will  cut  out  from  behind  forward. 
This  will  leave  a  fistula,  or  the  tissues  in  front  will  become  sufficiently 
strangulated  to  set  up  some  inflammatory  action,  resulting  afterwards 
in  a  labial  abscess. 

The  twisted  sutures  are  to  be  left  several  inches  long,  and  are  to 
be  secured  by  the  same  method  as  when  used  for  simple  laceration  of 
the  perineum.  I  have  met  with  but  few  instances  where  the  lacera- 
tion was  so  extensive  beyond  the  sphincter,  that  the  whole  extent  of 
the  fissure  could  not  be  included  within  the  deep  sutures  passed  as 
I  have  described.  When  the  exception  has  occurred,  the  difficulty 
was  easily  obviated  by  denuding  the  edges,  and  bringing  them  to- 
gether by  a  sufficient  number  of  interrupted  sutures  down  to  the  edge 
of  the  sphincter  ani.  These  sutures  were  introduced  at  a  sufficient 
distance  apart  (the  same  as  for  bringing  together  the  edges  of  a 
fistula),  then  twisted,  bent  over  flat  to  the  vaginal  surface  and  cut 
short.  The  after-treatment  will  differ  but  little  in  detail  from  that 
already  described. 

When  the  nurse  is  an  inexperienced  one,  I  have  the  patient's  bowels 
moved  by  castor  oil  on  the  sixth  day,  and  remove  the  sutures  the  day 
afterwards.  But,  if  the  nurse  has  been  accustomed  to  the  charge  of 
such  cases,  I  withdraw  the  sutures  at  the  end  of  a  week,  and  have  the 
bowels  moved  a  few  days  later,  since  trained  nurses  learn  to  support 
the  parts  with  their  fingers  while  the  bowels  are  acting,  so  as  to  re- 
lieve the  recently  united  surfaces  from  all  strain.  It  is  a  good  plan  to 
have  a  small  quantity  of  warm  olive  oil  gently  thrown  into  the  rectum 
just  before  the  bowels  are  moved.  After  the  sutures  have  been  re- 
moved, and  by  the  method  already  described,  the  bowels  must  be 
constipated  for  six  or  seven  days  by  regulating  the  diet,  and  by 
the  administration  of  opium,  if  needed,  in  sufficient  quantity  to  keep 
them  quiet.  The  knees  are  to  be  kept  tied  together  for  several  days 
after  the  removal  of  the  sutures,  and  always  at  night  for  some  time 
longer.  The  circumstances  of  the  case,  particularly  the  extent  of 
union,  will  indicate  the  proper  time  when  the  patient  may  be  allowed 
to  sit  up. 

It  is  yet  a  mooted  question  how  soon  after  the  injury  the  operation 
should  be  performed.  When  the  laceration  has  extended  through 
the  sphincter,  my  conviction  is  that  in  every  instance,  when  it  is 
possible  to  do  so,  the  parts  should  be  brought  together  immediately 
after  delivery.  It  is  true,  observation  has  taught  us  that  the 
lochial  discharge  is  poisonous  to  a  healing  surface,  yet  a  lai'ge  number 


406  LACERATION    OF    THE    PERINEUM. 

of  these  operations  would  be  successful  with  a  little  additional  care. 
The  operation  just  after  delivery  would  then  he  comparatively  a 
simple  one,  and  it  would  he  unnecessary  to  pass  the  suture  hehind 
the  muscle.  Something  would  ha  gained  in  every  case,  and  support 
would  he  given  to  the  uterus,  for  a  while  at  least,  until  it  had  become 
somewhat  reduced  in  size,  and  time  gained  for  the  overstretched 
vaginal  tissues  to  recover  their  tone.  A  week  even  thus  gained  in 
giving  a  proper  support  to  the  parts  may  be  the  means  of  saving  the 
patient  from  the  necessity  of  undergoing  treatment  for  months.  This 
she  may  be  spared,  even  if  the  operation  itself  should  prove  a  failure. 

The  condition  of  the  patient  after  delivery  may  be  too  critical  to 
admit  of  the  additional  operation  for  bringing  together  the  edges  of 
an  extensive  laceration  through  the  septum.  Under  these  circum- 
stances, I  should  deem  it  advisable  to  introduce  the  deep  perineal 
sutures,  to  include  as  much  of  the  septum  beyond  the  muscle  as  is 
possible.  These  sutures  can  be  rapidly  introduced,  and  without  any 
special  care  beyond  including  a  liberal  amount  of  tissue.  If  a  union 
of  the  perineum  is  thus  gained,  with  portion  of  the  septum  beyond 
the  sphincter,  but  a  small  recto-vaginal  fistula  will  remain.  This  may 
prove  a  discomfort,  but  its  closure  can  be  safely  deferred. 

I  am  in  the  habit  of  closing  this  little  opening  by  dividing  the  peri- 
neum and  sphincter  ani  by  means  of  a  pair  of  scissors.  Then  the 
edges  of  the  opening  can  be  thoroughly  denuded,  a  procedure  other- 
wise very  difficult.  The  parts  can  then  be  brought  together  and 
treated  in  every  respect  as  if  it  were  a  case  of  laceration  in  which 
the  surfaces  had  just  been  freshened. 

I  have  several  times  closed  such  an  opening,  after  denuding  the 
edges,  by  passing  the  sutures  around  the  fistula  from  the  perineum. 
With  the  finger  in  the  rectum  as  a  guide,  a  suture  was  passed  so  as 
to  close  the  edge  on  the  rectal  side,  and  another  above  for  the  vaginal 
border.  The  lower  suture  includes  so  much  of  the  sphincter  ani 
muscle,  that  its  action  in  the  upper  part  is  controlled.  By  this  means 
the  fistula  closes,  a  result  which  is  almost  impossible  to  be  obtained 
under  ordinary  circumstances,  since  the  outer  fibres  of  the  muscle 
form  one  side  of  the  fistulous  opening. 

When  an  operation  cannot  be  resorted  to  immediately  after  the 
injury,  the  knees  should  be  kept  tied  together,  the  urine  properly 
drawn,  and  the  greatest  care  given,  by  cleanliness,  to  free  the  parts 
from  irritation.  At  the  reception  of  the  injury,  the  rent  through  the 
septum  is  more  extensive  than  after  the  edges  have  cicatrized  ;  there- 
fore, if  proper  care  be  taken,  by  frequent  injections  of  tepid  water, 


author's  operation.  407 

to  keep  the  parts  free  from  irritating  discharges,  the  edges  will  unite 
to  within  a  short  distance  of  the  sphincter.  Before  the  patient  is 
allowed  to  assume  the  upright  position,  some  mechanical  support  must 
be  resorted  to  for  the  purpose  of  lifting  the  uterus  from  the  floor  of 
the  pelvis.  The  cfibrt  must  also  be  made  to  keep  the  organ  partially 
anteverted,  so  that  there  may  be  no  prolapse  of  the  vaginal  walls. 

After  the  woman  has  recovered  her  strength,  if  the  child  has  been 
stillborn,  the  operation  should  be  performed  without  further  delay. 
For  the  welfare  of  the  child,  if  the  mother  nurses  it,  the  operation 
should  be  deferred  until  it  is  old  enough  to  be  weaned  with  safety. 
But,  at  the  same  time,  we  must  take  into  consideration  the  condition 
of  the  mother,  as  to  how  long  she  may  be  safely  subjected  to  the  delay, 
care  being  had  always  to  keep  the  uterus  well  supported. 


408  INVERSION    OF    THE    UTERUS. 


CHAPTER    XXI. 


INVERSION  OF  THE  UTERUS. 


Causes  —  Frequency  —  Symptoms  —  Diagnosis  —  Treatment — Method  of  Valentin, 
White,  Tyler  Smith,  Noeggerath,  Courty,  Simpson,  Barnes,  Nott,  Emmet. 

Inversion  of  the  uterus  is  a  condition  in  which  the  uterus  has  be- 
come either  partially  or  completely  turned  inside  out,  so  that  more  or 
less  of  the  inner  surface  forming  the  uterine  canal  projects  through  the 
dilated  os  into  the  vagina.  The  injury  results  from  childbirth,  or 
from  the  growth  of  some  interstitial  tumor  which  had  already  begun 
to  project  into  the  uterine  canal. 

Dr.  West^  makes  the  following  statement :  "  No  instance  has  come 
under  my  observation  of  uterine  inversion  in  the  recent  state,  and, 
indeed,  the  annals  of  the  Dublin  Lying-in  Hospital,  and  those  of  the 
London  ^Maternity  Charity,  sufficiently  illustrate  the  rarity  of  the  acci- 
dent, since  it  was  not  once  met  with  in  a  total  of  more  than  140,000 
labors."     The  accident  is,  therefore,  comparatively  a  rare  one. 

It  has  become  a  tradition  in  the  profession,  that  inversion  of  the 
uterus  is  in  some  manner  always  due  to  traction  made  on  the  umbili- 
cal cord  in  the  delivery  of  the  placenta.  Under  certain  circumstances, 
and  from  the  employment  of  great  force,  it  is  possible,  with  the  pla- 
centa attached  directly  at  the  fundus,  that  inversion  may  sometimes 
take  place,  but  I  believe  the  injury  is  rarely  due  to  this  cause.  If  it 
were  due  to  this  cause,  the  lesion  should  be  a  more  common  one,  as 
the  result  of  all  the  pulling  upon  the  cord  which  has  been  employed, 
down  to  the  present  day,  by  all  the  old  women  to  be  found  both 
within  and  without  the  profession. 

Schroedei-^  offers  the  following  explanation  :  "  Inversion  is  doubtless 
brought  about  in  this  way — the  uterine  foundation,  or  base  of  the 
tumor,  which  consists  of  normal  uterine  tissue,  becomes  atrophied 
(either  disappearing  or  undergoing  fatty  degeneration)  by  means  of 
the  pressure  which  the  tumor  exerts.  A  gap  is  thus  formed  in  the 
firm  contractile  uterine  tissue  ;  the  tumor  sinks  into  the  cavity  of  the 

'  Lectures  on  the  Diseases  of  Women,  p.  231. 
2  Ziemsseu's  Cyclopaedia,  vol.  x.  p.  215. 


CAUSES.  409 

womb,  and  is  driven  towards  the  mouth  both  by  its  own  weight  and 
by  the  contractions  of  the  organ.  The  os  then  opens,  and  the  tumor 
sinks  into  the  canal  of  the  cervix,  and  thus  the  adjacent  portions  of 
the  uterine  wall  being  drawn  down,  a  complete  eversion  is  gradually 
accomplished.  In  some  cases,  however,  after  the  tumor  has  sunk  a 
certain  distance  into  the  cavity  of  the  uterus,  the  inversion  is  rapidly 
accomplished  by  means  of  uterine  contraction." 

These  views  are  unquestionably  correct,  and  are  in  accordance  with 
my  own  observation.  By  reference  to  the  chapter  on  fibrous  tumors 
in  this  work,  essentially  the  same  explanation  will  be  found  as  Avas 
offered  by  me  several  years  ago,  in  reference  to  the  method  by  which 
tumors  become  pedunculated.  During  an  operation  on  a  case  in 
March,  1874,  with  my  hand  in  the  uterus  I  was  able,  for  the  first 
time,  to  appreciate  accurately  the  process.  I  then  advanced  the 
opinion,  and  have  frequently  advocated  it  since,  that  inversion  of  the 
uterus  resulted  in  the  manner  described,  by  irregular  and  segregate 
contractions  of  the  muscular  tissue. 

As  a  nile,  inversion  takes  place  between  the  birth  of  the  child  and 
the  delivery  of  the  placenta.  It  is  marked,  generally,  by  symptoms 
of  sudden  shock  and  hemorrhage,  but  out  of  proportion  to  the  actual 
loss  of  blood,  which,  although  often  free  and  continuous,  is  frequently 
not  detected  before  the  collapse.  The  contractions  of  the  uterus 
afterwards  are  often  violent,  and  cause  much  suffering  from  reflex 
irritation  of  the  bladder  and  rectum.  Under  other  circumstances  the 
accident  has  been  attended  with  so  little  disturbance  that  the  question 
may  remain  an  unsettled  one  as  to  the  exact  time  of  its  occurrence. 
Cases  of  this  description  have  been  reported  where  the  inversion  was 
supposed  to  have  taken  place  days  after  delivery,  and  others  where 
the  condition  was  only  detected  by  accident,  presenting  no  symptom 
of  disease  other  than  a  watery  discharge  or  a  leucorrhoea. 

An  inversion  of  the  uterus  is,  however,  generally  accompanied  by 
a  constant  oozing  of  blood,  which  eventually  produces  a  most  profound 
degree  of  anaemia.  There  will  be  an  inability  to  exercise,  and  in 
some  cases  oedema  of  the  face  as  well  as  of  the  extremities.  On 
assuming  the  upright  position,  nausea  or  vomiting  is  frequently  ex- 
cited, with  palpitation  and  irregular  action  of  the  heart,  all  of  which 
symptoms  are  due  to  the  loss  of  blood.  Instances  have  occurred 
where  women  have  had  the  vitality  to  resist  the  consequences  of 
inversion  of  the  uterus  for  twenty  or  thirty  years,  until,  at  length, 
with  a  change  of  life  the  drain  has  ceased. 

There  can  scarcely  be  any  difiiculty,  just  after  an  inversion,  in 
forming  a  diamosis  when  resulting  from  childbirth.     The  uterus  at 


410 


INVERSION    OF    THE    UTERUS. 


this  time  is  generally  large  enough  to  project  from  the  vagina,  and 
frequently  has  the  placenta  still  adherent  to  it.  But  after  the  uterus 
has  contracted  to  nearly  its  natural  size,  it  may  become  a  difficult 
matter  to  make  the  diagnosis  between  an  inversion  and  a  pedunculated 
fibroid. 

Fig.  75  illustrates  the  usual  condition  existing  with  the  inversion 
of  the  uterus  to  the  vaginal  junction,  the  fundus  being  seen  projecting 
into  the  vagina  through  the  ring  formed  by  the  dilated  cervix. 

Fig.  75. 


Inversion  of  the  uterus. 


In  this  instance  the  use  of  the  sound  would  indicate,  under  ordinary 
circumstances,  the  condition,  since  it  could  only  be  introduced  between 
the  mass  and  the  cervix,  to  the  same  depth  on  all  sides.  But  occasion- 
ally other  lesions  are  met  with  which  might  mislead  and  render  a 
diagnosis  doubtful.  Several  instances  have  occurred  in  this  city,  and 
many  others  are  on  record,  where  the  mistake  has  been  made  in 
removing  an  inverted  uterus  for  a  supposed  polypus.  It  is,  therefore, 
most  important  to  determine  accurately  the  true  condition,  and  always 
to  treat  the  case  as  one  of  inversion  so  long  as  any  doubt  exists, 
otherwise  a  simple  operation  for  the  removal  of  a  polypus  may,  in  an 
inversion  of  the  uterus,  prove  a  fatal  error. 

I  have  myself  tightened  the  chain  of  an  dcraseur  around  the  pedicle 


DIAGNOSIS.  411 

of  a  supposed  polypus,  which  was  attached  to  the  fundus  at  a  distance 
of  over  two  and  a  half  inches  from  the  cervix,  where,  on  further  in- 
vestigation, the  case  proved  to  be  one  of  inversion.  In  this  instance 
the  uterus  was  enlarged,  and  a  fibroid  at  the  fundus,  which  had 
caused  the  inversion,  stretched  out  by  its  weight  the  body  to  such  an 
extent  that  it  was  not  larger  than  the  index  finger,  thus  giving  it 
every  appearance  of  being  the  pedicle  of  a  fibroid.  Then,  to  add  to 
the  deception,  the  sound  passed  to  a  natural  depth  alongside  of  this 
nrxass  into  what  was  supposed  to  be  the  whole  uterine  canal.  The 
diagnosis  was  not  settled  until,  by  means  of  the  chain  of  the  ^craseur, 
the  mass  had  been  drawn  down  to  the  vaginal  outlet,  Avhen,  on  passing 
the  finger  into  the  rectum,  the  indented  portion  at  the  seat  of  inversion 
was  distinctly  felt.  This  could  not  be  reached  before,  or  detected 
through  the  abdominal  wall,  on  account  of  the  thickness  of  the  adi- 
pose tissue. 

Within  a  few  days  of  writing  this  article  a  case  was  under  observa- 
tion at  the  Woman's  Hospital,  where  the  existence  or  not  of  an  in- 
version could  not  be  determined.  The  woman  was  very  fleshy,  there 
was  scarcely  any  pedunculated  shape  in  the  mass,  and  at  one  side 
only  could  a  sound  be  introduced  to  a  greater  depth  than  an  inch, 
beyond  which,  for  some  two  inches  and  a  half,  it  seemed  to  pass 
only  into  the  opposite  horn  of  the  uterus.  I  had  made  a  diagnosis 
at  first  of  a  polypus,  but  on  a  further  examination  the  case  seemed 
to  be  one  of  inversion  commencinjz;  at  the  riorht  horn  of  the  uterus. 
I  attempted  for  an  hour  and  a  half  to  reduce  it,  but  without 
success.  After  an  interval  of  a  week  I  passed  a  slip-knot  of  tape 
high  up  around  the  mass,  by  introducing  the  hand  into  the  vagina, 
and  by  this  means  gently  drew  it  down  to  the  outlet.  I  now  dis- 
covered a  difference  in  the  character  of  the  tissue  covering  the  mass, 
and  as  no  constriction  could  be  detected  by  examination  through  the 
rectum,  the  probabilities  were  in  favor  of  a  fibroid.  After  some 
difficulty,  I  enucleated  a  tumor  nearly  as  large  as  a  hen's  egg,  Avhich 
had  been  crowded  out  from  the  uterine  wall,  and  with  it  a  thick  layer 
of  uterine  tissue  covered  by  mucous  membrane,  so  as  to  present  all 
the  appearances  of  an  inversion. 

Some  years  ago,  the  late  Dr.  Henschel  exhibited,  to  the  New  York 
Obstetrical  Society,  a  specimen  of  polypus  which  projected  into  the 
vagina,  and  had  become  adherent  all  around  to  the  sides  of  the  cervical 
canal,  so  that  a  probe  could  not  be  passed  in  any  direction. 

Dr.  Sussdorff,  of  this  city,  has  reported'  a  case  of  hollow  polypus 

•  Am.  Journ.  of  Obstetrics,  etc.,  Oct.  1877. 


412  INVERSION  OF  THE  UTERUS. 

whicli  was  attached  in  the  same  manner,  and  to  increase  the  difficulty 
of  diagnosis,  the  uterus  was  afterwards  found  completely  retroverted. 
This  condition  could  not  have  been  detected  under  the  circumstances, 
without  taking  the  precaution  of  introducing  a  finger  into  the  rectum 
and  another  into  the  vagina  at  the  same  time.  Unless  adopting  this 
method,  the  retroverted  uterus,  as  felt  from  the  rectum,  would  natu- 
rally be  mistaken  for  the  tumor  in  the  vagina,  and  in  the  absence  of 
the  uterine  body  from  the  relative  position  it  should  occupy,  the  diag- 
nosis of  inversion  of  the  uterus  would  be  a  natural  One. 

It  has  been  stated  that  pain  could  be  excited  by  grasping  the  mass 
if  it  were  an  inversion,  while  the  contrary  would  be  the  case  with  a 
polypus.  This  I  have  noticed  in  several  instances  in  which  also  con- 
traction was  excited,  but  with  other  cases  the  uterus  had  become  as 
little  sensitive  as  a  polypus. 

Under  ordinary  circumstances  the  existence  of  an  inversion  can  be 
determined  by  the  history  of  the  case  ;  by  the  absence  of  the  uterine 
body  from  its  natural  position,  as  shown  by  the  facility  with  which  a 
sound  in  the  bladder  and  a  finger  in  the  rectum  may  be  approximated 
at  that  point ;  and,  beyond  question,  on  detecting  the  cavity  formed 
at  the  seat  of  inversion ;  and  by  using  the  probe  to  ascertain  the 
depth  of  the  uterine  canal. 

Treatment. — Unless  the  accident  were  recognized  early  enough 
after  labor  to  return  the  fundus  before  the  organ  had  contracted,  there 
existed,  until  recently,  no  other  practice  but  the  removal  of  that  por- 
tion of  the  uterus  projecting  below  the  point  of  inversion.  I  may  be 
trenching  somewhat  on  the  province  of  the  accoucheur  in  treating  of 
an  inversion  which  has  just  occurred,  but  unless  I  do  so  the  history  of 
the  lesion  will  be  scarcely  complete. 

When  inversion  takes  place,  with  the  placenta  still  attached,  the 
question  may  arise  as  to  the  proper  treatment.  While  all  authorities 
would  agree  as  to  the  necessity  for  an  immediate  reduction,  there  may 
exist  a  difference  of  opinion  as  to  the  removal  of  the  placenta  through 
fear  of  hemorrhage.  To  attempt  the  reduction  with  the  placenta 
attached  would  prove  a  very  difficult  procedure,  and  even  were  the 
necessity  greater  for  doing  so,  the  loss  of  time  which  it  would  neces- 
sitate, in  consequence  of  the  contraction,  might  well  be  advanced  as  a 
serious  objection.  The  fear  of  hemorrhage,  however,  I  suspect  is 
based  entirely  upon  theoretical  views,  drawn  from  false  premises,  since 
the  uterus  could  not  become  inverted  unless  from  contraction,  and  this 
condition  is  not  one  favorable  to  a  prolonged  loss  of  blood.  The  uterus 
continues  to  contract  rapidly  afterwards,  and  the  great  fear  lies  in  the 
loss  of  time  Avhich  may  thus  render  the  reduction  difficult.    I  advocate 


TREATMENT.  413 

the  removal  of  the  placenta,  and  the  immediate  carrying  up  of  the 
fundus  to  its  proper  position,  when  possible,  by  introducing  the  hand 
into  the  vagina.  The  uterus  in  this  state  will  at  times  contract  vio- 
lently, and  then  become  relaxed.  If  the  uterus  should  have  already 
become  much  reduced  in  size,  it  will  be  impossible  to  return  the  fundus 
Avhile  the  organ  is  in  the  state  of  contraction.  It  Avill  first  be  neces- 
sary to  indent  some  part  of  the  fundus,  in  the  interval  of  relaxation, 
and  this  portion  may  be  then  rapidly  carried  up  on  the  point  of  the 
finger.  While  the  reduction  is  progressing,  a  bed-pan  can  be  placed 
under  the  hips,  and  a  basin  of  hot  water  procured.  Then  the  opera- 
tor, without  removing  the  hand,  may,  with  the  other,  introduce  the 
long  nozzle  of  a  Davidson's  syringe  within  the  uterine  canal.  The 
injection  of  hot  water  will  certainly  excite  reflex  action,  so  that  the 
bleeding,  if  it  should  exist,  will  be  arrested,  as  in  post-partum  hemor- 
rhage, and  after  reduction,  the  inversion  cannot  again  take  place,  in 
consequence  of  contraction  of  the  whole  uterus. 

Not  being  in  obstetrical  practice,  I  have  never,  myself,  tested  the 
action  of  hot  water  in  such  a  case.  But  I  have  no  doubt  of  its  value, 
since  I  have  for  more  than  ten  years  urged  in  my  clinics  and  among 
my  friends  its  use  in  post-partum  hemorrhage,  to  bring  about  the 
usual  condition  of  contraction.  The  remedy  is  certainly  most  effica- 
cious for  the  purpose,  if  it  be  properly  applied  within  the  uterus,  at  a 
high  temperature,  and  in  sufficient  quantity. 

I  can,  beyond  question,  claim  the  credit  of  having  first  recommended 
its  use  for  this  purpose,  based,  not  upon  theoretical  views,  but  upon 
actual  practice.  I  had  already,  for  years  before,  been  familiar  with 
its  action  in  exciting  uterine  contraction  whenever  I  removed  a  tumor 
from  Avithin  the  uterus. 

As  already  stated,  the  condition  was  regarded  as  a  hopeless  one 
after  the  uterus  had  once  contracted,  and  from  the  practice  of  Am- 
brose Pard  down  to  the  present  generation  the  ligature  was  the  only 
resort,  with  or  without  the  aid  of  the  knife  afterwards.  The  late  Dr. 
Charles  D.  Meigs,  of  Philadelphia,  in  his  Letters^  to  the  students  of 
his  class  in  1846,  wrote  :  "You  might  as  well  try  to  invert  one  of  the 
non-gravid  uteri  on  my  lecture-room  table  as  to  reposit  this  one — the 
time  is  gone  by."  He  had  reference  to  the  possibility  of  restoring 
the  inversion  after  the  organ  had  contracted.  Yet  he  cites  two  cases 
which  occurred  in  his  own  practice,  of  spontaneous  recovery,  followed 
by  pregnancy,  where  his  diagnosis  as  to  the  inversion  had  been  con- 
firmed by  Prof.  Hodge  and  Dr.  Warrington.     No  reasonable  doubt 

'  Woman :  her  Diseases  and  Remedies. 


414  INVERSION    OF    THE    UTERUS. 

could  be  advanced,  as  to  the  correctness  of  the  diagnosis,  by  any  one 
familiar  with  the  skill  of  these  gentlemen.  Dr.  Meigs,  in  his  work, 
refers  also  to  other  similar  instances,  but  they  are  not  from  so  authen- 
tic a  source,  and  the  question  of  an  error  of  diagnosis  might  be  raised. 

A  number  of  cases  of  inversion  of  the  uterus  have  been  reported  to 
the  medical  journals,  and  others  are  to  be  found  in  the  earlier  works, 
where  the  accident  had  been  recognized  and  the  reduction  accom- 
plished almost  immediately  after  the  occurrence.  The  uterus  is 
generally  well  contracted  in  twelve  hours,  and  with  many  cases  it 
would  be  then  quite  as  difficult  to  effect  a  reduction  as  if  a  year  had 
elapsed.  Nevertheless,  I  have  found  on  record  that  Dr.  Eb.  Skae,^ 
of  Edinburgh,  in  1845,  reduced  the  displacement  twelve  hours  after 
its  occurrence,  which  followed  a  miscarriage  at  four  months.  In  con- 
sequence of  the  inversion  from  a  miscarriage  this  case  is  notable.  In 
1847,  Dr.  E.  H.  McCoy,  of  Harrisville,  Ohio,  reported^  a  case  he 
had  reduced  two  days  after  delivery.  This  case  seems  to  have  been 
the  first  reduced  in  this  country  after  so  long  a  delay  had  intervened 
from  the  delivery. 

The  publication  of  M.  Valentin's  case  {Revue  Medico- OMrurg., 
Nov.  1847^),  showing  that  he  had  succeeded  in  reducing  the  uterus 
sixteen  months  after  it  became  inverted,  established  the  operation  as 
a  feasible  one,  and  afforded  a  definite  plan  of  procedure.  After 
describing  the  mode  of  delivery  (which  occurred  April  8,  1846)  and 
the  condition  of  the  woman  for  a  year  afterwards,  his  method  of 
reduction  is  given  as  follows :  "After  several  months  devoted  to  the 
recruiting  the  strength,  on  the  15th  of  August,  1847,  the  vagina  was 
dilated  by  sponge  tents,  and  the  female  was  placed  on  the  edge  of 
the  bed,  as  for  the  application  of  forceps.  The  left  hand  of  the 
operator  then  grasped  the  hypogastrium,  the  uterus  itself  was  seized 
by  the  fingers  and  thumb  of  the  right  hand,  and  pressure  made  ;  but 
the  screams  of  the  patient  caused  the  operation  to  be  for  the  time 
abandoned. 

"  On  the  26th  another  attempt  was  made,  Avith  the  aid  of  ether 
inhalation.  The  patient  being  rendered  insensible,  the  same  manipu- 
lations were  gone  through  with,  but,  as  before,  the  uterus  was  altered 
in  form,  Avithout  the  fundus  yielding,  as  was  wished.  The  attempt 
was  persisted  in  for  ten  minutes  without  progress,  when  etherization 

•  Ranking's  Abstract,  American  edition,  January,  1847. 

2  American  Journal  of  the  Mi^dical  Sciences,  July,  1847. 

3  Ranking's  Abstract,  American  edition,  January,  1848. 


TREATMENT.  415 

was  carried  to  the  extent  of  reducing  relaxation  of  the  sphincter.-!. 
At  this  moment  the  collapse  of  the  system  was  complete,  and,  the 
uterus  partaking  of  the  relaxation,  the  fundus  allowed  itself  to  he 
depressed  under  the  finger,  until,  at  length,  it  became  suddenly 
restored  to  its  normal  state." 

Dr.  S.  W.  Merriman  reports^  a  reduction  performed  by  M.  Barrier, 
of  Lyons.  Chloroform  was  used,  and  very  much  the  same  method 
was  employed  as  that  given  by  Valentin.  The  duration  of  the  dis- 
placement is  not  stated,  but  the  inference  is  that  it  was  about  eighteen 
months. 

Islr.  George  Canney,  of  Bishop-Auckland,  gives^  another  successful 
case,  after  five  month's'  inversion.  The  same  plan  of  reduction  was 
followed,  chloroform  being  also  employed. 

To  the  late  Dr.  John  Y.  Quackenbush,  of  Albany,  N.  Y.,  is  doubt- 
less due  the  credit  of  having  been  the  first  in  this  country  to  reduce 
a  chronic  inversion  of  the  uterus.  He  is  even  entitled  to  greater 
credit,  since,  as  I  have  been  informed  by  himself,  at  the  time  of  ope- 
rating he  regarded  the  procedure  as  original,  and  was  ignorant  of 
the  success  of  Yalentin  and  others  before  him.  The  reduction  was 
performed  by  Dr.  Quackenbush  April  29,  1855,  and  reported  to  the 
New  York  State  Medical  Society  February  3,  1859. 

The  next  to  make  the  attempt  in  this  country  was  Prof.  James  P. 
White  of  Buffalo,  who  operated  March  12,  1858,  and  reported  the 
case  to  the  Buffalo  Medical  Association  in  the  following  April, ^ 
The  inversion  had  existed  for  fifteen  years.  Dr.  Tyler  Smith,  of 
London,  operated  for  the  first  time  in  1856,  but  his  report  of  the  case 
was  only  made  to  the  Royal  Medical  and  Chirurgical  Society,  April 
13,  1858,  In  this  instance,  the  inversion  had  been  of  twelve  years' 
standing.  Dr,  Noeggerath,  of  New  York,  reported  a  successful  case 
in  the  American  Medical  Times,  1862,  which  had  been  of  thii'teen 
years'  duration.  Since  this  time  the  operation  has  been  generally 
accepted  by  the  profession,  and  the  number  of  successful  cases,  both 
in  this  country  and  abroad,  lias  rapidly  increased.  As  a  conse- 
(j;uence  of  increased  experience,  no  operator  of  the  present  day  would 
abandon  any  case  on  the  plea  of  being  irreducible.  Prof.  White  has 
operated,  and  with  success,  on  a  larger  number  of  cases  than  any 
other  member  of  the  profession. 

Since  no  one  method  yet  proposed  is  applicable  to  the  reduction  of 

'  Medical  Times  and  Gazette,  Sept.  4,  18:)2.  2  Ibid.,  Sept.  18,  1852. 

'  American  Journal  of  the  Medical  Sciences,  July,  1858. 


416 


INVERSION    OF    THE    UTERUS. 


every  case,  various  expedients  have  been  resorted  to  under  the  differ- 
ent circumstances. 

Preparation  for  the  Operation. — Under  all  circumstances  the  con- 
tents of  the  rectum  and  bladder  must  be  removed  before  commencino; 
the  operation.  An  anjesthetic  is  indispensable.  The  position  which 
seems  to  have  been  universally  settled  upon  as  the  best  for  the  opera- 
tion is  that  on  the  back,  with  the  lower  limbs  drawn  up  and  flexed  on 
the  abdomen,  and  thus  held  by  an  assistant  standing  on  each  side. 
The  hands  of  the  operator  must  be  thoroughly  washed  and  softened 
in  warm  water.  One  hand,  with  the  forearm  bared  and  well  greased, 
is  carefully  passed  into  the  vagina,  to  execute  any  special  manipulation 
decided  upon,  while  the  other  hand  is  to  be  employed  for  steadying 
the  uterus  by  making  counter-pressure  above  the  pubes. 

Valentin's  method  has  already  been  described,  and  is  the  one  which 
would  naturally  be  suggested.  Br.  Quackenbush,  in  his  case,  em- 
ployed essentially  the  same  plan. 

WJiite'h  method. — One  hand  is  introduced  into  the  vagina  for  the 
double  purpose  of  grasping  the  inverted  portion  of  the  uterus  and,  at 


Ym.  76. 


White's  Ropositor. 


the  same  time,  keeping  pressed  against  the  fundus  an  India-rubber 
cup,  from  which,  projecting  outwards,  is  a  short  staff,  having  at  its 
other  end  a  stout  steel  spiral  spring  (see  Fig.  70).  This  spring  has 
a  pad  at  its  extremity  (not  shown  in  the  figure),  and  is  intended  to 


MODES    OF    OPERATING.  417 

rest  against  the  body  of  the  operator,  so  as  to  maintain  a  steady  pres- 
sure. The  effect  of  this  is  to  put  the  vaginal  canal  on  the  stretch, 
so  that  by  traction  on  the  walls  the  ring  at  the  seat  of  inversion  above 
may  be  dilated.  The  other  hand  is  employed  to  steady  the  uterus, 
and,  at  the  proper  time,  to  aid  by  making  counter-pressure,  with  the 
view  of  rolling  out  the  tissues  at  tlie  seat  of  inversion. 

Tyler  Smithes  method  was  to  mould  and  compress  with  the  fingers 
the  inverted  portion  of  the  uterus  every  night  and  morning  for  ten 
days,  and  then  to  keep  up  steady  pressure  by  fully  distending  the 
vagina  with  an  inflated  India-rubber  bag.  At  the  end  of  a  week  it 
was  found  that  the  uterus  was  returned  to  its  normal  position. 

NoeggeratJi's  ?7ie^/i06?  consists  in  compressing  the  body  of  the  uterus, 
opposite  to  each  horn,  between  the  thumb  and  finger,  so  as  to  indent 
it  on  one  side  or  the  other.  When  this  can  be  accomplished,  the  in- 
dented hom  of  the  uterus  is  crowded  like  a  wedge  into  the  canal 
formed  by  the  inversion,  and  it  is  then  soon  followed  by  the  remainder 
of  the  fundus  and  whole  body  of  the  uterus.  This  plan  has  been 
attended  with  success  in  several  instances  to  my  knowledge,  and  it  is 
particularly  applicable  for  recent  cases  of  inversion. 

Courty' 8  metliod^  as  described  in  his  work,  was  in  one  instance 
successfully  employed  after  other  means  had  failed.  The  uterus  was 
drawn  down  by  a  vulsellum  to  the  vaginal  outlet,  two  fingers  were 
then  passed  into  the  rectum  and  separated  so  as  to  hook  over  the 
mass  on  each  side  of  the  seat  of  inversion  along  the  utero-sacral  liga- 
ments. Firm  pressure  was  now  made  with  the  other  hand  in  the 
vagina,  by  grasping  the  pedicle  or  body  of  the  uterus,  and  pushing 
it  backward.  The  mechanical  effect  would  be  exerted  with  little  loss 
of  force,  since  the  fingers  in  the  rectum  steady  the  uterus,  and,  from 
their  position,  aid  in  rolling  out  the  edges  at  the  seat  of  inversion  as 
the  body  is  being  crowded  up  from  below  by  the  hand  in  the  vagina. 

Simpson'' 8  and  Thomas's  Method. — Accordingto  Dr.  Robert  Barnes,' 
"  this  consists  in  making  an  incision  through  the  abdominal  wall  so 
as  to  get  at  the  constricted  os  uteri  from  above,  and  then  applying  a 
dilating  force.  The  idea  Avas  enunciated  by  the  late  Sir  James 
Simpson  at  the  discussion  of  my  paper  before  the  Medico-Chirurgical 
Society  in  1869."  Dr.  T.  G.  Thomas,  of  New  York,  has  been  bold 
enough  to  put  this  suggestion  into  successful  practice  in  two  instances, 
with  the  result  of  death  from  peritonitis  in  one  of  the  cases.  From  a 
conservative  stand-point,  I  should  not  advocate   the   practice.     Dr. 

'  American  edition  of  his  work,  page  632. 
27 


418  INVERSION  OF  THE  UTEEUS. 

Thomas  frankly  states  that  the  ahdominal  section  "  is  not  oifered  as  a 
method  for  treating  inversion  of  the  uterus,  but  as  a  substitute  for 
amputation." 

Barnes's  Method} — In  1868,  Dr.  Barnes,  having  failed  in  the  re- 
duction by  Dr.  Tyler  Smith's  plan,  drew  down  the  inverted  uterus  to 
the  vulva  by  a  slip-knot  of  tape.  "  I  then,"  he  says,  "  made  three 
incisions  in  the  neck  about  a  third  of  an  inch  deep,  one  on  each  side, 
and  one  behind  in  a  longitudinal  direction,  that  is,  across  the  fibres  of 
the  cervical  sphincter.  Then,  compressing  the  uterus  with  my  left 
hand,  and  supporting  the  os  uteri  by  the  fingers  of  the  right  hand 
through  the  abdominal  wall,  I  found  the  cervix  yield,  and  the  body 
went  through  into  its  place.  The  cervix  yielded  by  laceration  ex- 
tending from  the  incisions,  and  I  very  much  feared  at  the  time  that 
serious,  if  not  fatal  mischief  had  been  done.  No  material  inconven- 
ience, however,  followed ;  an  examination  three  weeks  afterwards 
showed  the  cervix  and  uterus  to  be  in  their  proper  places.  Notwith- 
standing the  successful  issue,  I  believe  that  the  method  should  only 
*be  resorted  to  after  a  full  trial  of  Tyler  Smith's  plan,  and  then  with 
great  caution.  I  should  recommend  that  only  two  incisions  be  made, 
one  on  each  side  of  the  os,  and  these  of  moderate  depth."  This  ope- 
ration'has  been  put  in  practice  by  Drs.  Sims  and  Thomas,  and  Sir 
James  Simpson  also  recommended  it.  With  the  greater  number  of 
cases  the  hemorrhage,  as  in  Dr.  Thomas's  case,  must  be  excessive,  and 
the  procedure  should  not,  therefore,  be  adopted  except  as  a  last 
resort. 

Watts''s  Method. — Recently  Dr.  Robert  Watts  of  this  city,  has 
succeeded  in  reducing  a  case  of  inversion  at  the  Roosevelt  Hospital  in 
the  following  manner.  He  first  drew  down  the  uterus  so  as  to  make 
it  protrude  partially  from  the  vaginal  outlet,  and  then  passed  two 
fingers  into  the  rectum,  as  in  Courty's  method.  But,  instead  of  using 
the  fingers  in  the  rectum  simply  for  counter-pressure,  he  placed  a 
finger  in  the  depression  formed  at  the  seat  of  inversion.  Then,  by 
means  of  the  hand  grasping  the  uterus  at  the  mouth  of  the  vagina, 
the  organ  was  gradually  pushed  down  on  to  the  finger,  which  of  course 
carried  before  it  a  portion  of  the  anterior  rectal  wall.  He  then 
succeeded  in  getting  two  fingers  through  the  ring,  when  it  became 
sufficiently  dilated  for  the  fundus  to  be  pushed  up  on  the  point  of 
the  index  finger  without  further  difficulty,  and  the  restoration  was 
completed. 

'  Thomas  on  Diseases  of  Women,  page  636. 


author's  method.  419 

I  was  called,  as  one  of  the  Consulting  Board,  to  see  this  case  with 
Dr.  Watts  when  she  Avas  first  admitted  to  the  hospital.  She  was  a 
young  negro  Avoraan  who  had  given  birth  to  at  least  one  child,  but 
my  impression  is  that  the  time  of  inversion  could  not  be  accurately 
determined  by  her  history.  A  small  fibroid,  however,  was  found  at 
the  fundus  which  may  have  produced  the  inversion.  This  tumor  was 
enucleated,  and  attempts  at  reduction  were  made,  which  failed.  Subse- 
quently another  effort  was  undertaken  and  persevered  in.  I  assisted 
Dr.  Watts,  but  we  did  not  accomplish  more  than  to  advance  the  fundus 
within  the  cervix.  I  was  unable  to  assist  him  at  the  final  effort,  but 
after  resorting  to  the  plan  described,  the  reduction  was  rapidly  ac- 
complished. 

Emmet'' s  3Ietliocl. — In  1865  I  succeeded  in  effecting  a  reduction  by 
passing  my  hand  into  the  vagina,  and,  with  the  fingers  and  thumb 
encircling  the  portion  of  the  body  close  to  the  seat  of  inversion,  the 
fundus  was  allowed  to  rest  in  the  palm  of  the  hand.  This  portion  of 
the  body  was  firmly  grasped,  pushed  upward,  and  the  fingers  were 
then  immediately  separated  to  their  utmost ;  at  the  same  time  the 
other  hand  was  employed  over  the  abdomen  in  the  attempt  to  roll  out 
the  parts  forming  the  ring,  by  sliding  the  abdominal  parietes  over 
its  edge.  This  manoeuvre  was  repeated  and  continued.  At  length, 
as  the  transverse  diameter  of  the  uterine  cervix  and  os  was  increased 
by  lateral  dilatation  with  the  outspread  fingers,  the  long  diameter  of 
the  body  became  shortened,  and  the  degree  of  inversion  proportion- 
ately lessened.  After  the  body  had  advanced  well  within  the  cervix, 
steady  upward  pressure  upon  the  fundus  was  applied  by  the  tips  of 
all  the  fingers  brought  together. 

This  method  will  be  described  more  fully  in  the  history  of  several 
cases  which  are  to  be  presented  in  detail.  At  the  same  time  there 
will  be  given  a  plan  for  closing  the  lips  over  the  fundus  after  a 
partial  reduction  (and  this  may  essentially  be  included  in  Emmet's 
method),  for  the  purpose  of  preserving  for  a  time  the  advance  already 
gained,  or  to  prevent  a  recurrence  of  a  complete  inversion  when  the 
whole  amount  cannot  be  reduced. 

Case  XVI. ^ — Mrs.  Q.,  aged  24,  came  under  my  charge  Oct.  8, 1865. 
She  had  menstruated  for  the  first  time  at  eleven  years  of  age,  with 
no  return  for  a  year,  but  after  this  period  she  became  regular  and 
continued  in  perfect  health.  She  was  married  at  twenty-two  years 
of  age  ;  soon  afterwards  became  pregnant,  and  went  to  full  term. 
Labor  commenced  between  the  hours  of  nine  and  ten  P.  M.  March  11, 

•  Read  before  the  New  York  Obstetrical  Society,  Nov.  21,  1865. 


420  TNVEESION  OF  THE  UTERUS. 

1865.  About  eleven  A.  M.  the  membranes  were  ruptured,  and  de- 
livery of  a  large  male  child  took  place  an  hour  afterwards,  labor 
ha\ang  continued  nearly  thirteen  hours.  As  the  head  passed  the 
vulva,  it  was  discovered  that  the  umbilical  cord  had  made  several 
turns  around  the  child's  neck.  The  cord,  as  stated,  was  slipped  over 
the  head  without  traction,  the  body  followed  immediately,  and  soon 
afterwards  the  placenta.  Within  an  hour  after  delivery  the  patient 
suddenly  became  faint,  with  violent  after-pains  coming  on.  This  con- 
dition continued  for  forty-eight  hours  with  a  bloody  discharge,  which, 
at  the  time  of  each  pain,  was  expelled  from  the  vagina  with  con- 
siderable force.  After  the  pain  had  ceased,  the  flow  continued  more 
than  natural,  and  at  times  was  almost  of  pure  blood.  About  a  week 
after  delivery  the  nurse  discovered  a  mass  presenting  just  within  the 
vagina.  An  examination  was  made  by  the  attendant,  a  consultation 
called,  and  the  case  pronounced,  as  the  patient  stated,  one  of  cauli- 
flower growth.  At  the  end  of  a  month  her  general  health  became  so 
much  impaired  by  a  constant  sanguineous  discharge,  that  Dr.  Mc- 
Call,  of  Utica,  was  consulted,  and  he  recommended  her  to  ray  care. 
On  making  a  vaginal  examination,  a  soft  mass  somewhat  larger  than 
an  egg  was  felt  Ij^ing  in  the  axis  of  the  vagina,  and,  being  peduncu- 
lated, might  well  have  been  mistaken  for  a  polypus.  I  passed  two 
fingers  of  the  left  hand  well  up  into  the  cul-de-sac  behind  the  mass, 
so  as  to  lift  the  uterus  above  the  pubes,  and,  with  the  other  hand  over 
the  abdomen,  I  was  able  to  approximate  the  two  sufficiently  to  satisfy 
mvself  that  the  case  was  one  of  inversion.  She  presented  every  in- 
dication of  suffering  from  extreme  anaemia. 

Oct.  10.  Pulse  160  per  minute ;  at  12.30  P.  M.  she  was  placed 
under  the  influence  of  ether.  Since  it  was  a  serious  question  if  in 
her  reduced  condition,  the  anaesthetic  could  be  continued  long  enough 
to  eff"ect  the  reduction,  I  requested  Drs.  George  T.  Elliot,  Jr.,  Sabine, 
and  Thomas  to  aid  me  with  their  counsel.  She  came  fully  under 
the  influence  of  the  angesthetic  in  a  few  moments,  with  the  eff'ect  of 
reducing  the  pulse  in  frequency,  and  making  it  fuller. 

The  patient  had  been  placed  on  a  table  of  a  convenient  height  for 
me  to  operate  while  seated,  and  lay  on  the  back  with  knees  drawn  up. 
The  left  hand  was  passed  entirely  within  the  vagina,  and  by  pressure 
of  the  fingers  the  fundus  "dimpled,"  while  the  organ  was  steadied  by 
the  right  hand  over  the  abdomen.  At  the  end  of  an  hour  I  found 
that  little  progress  had  been  made,  but  the  fundus  had  become  some- 
what smaller  from  pressure. 

There  was  full  time  for  reflection,  when  it  became  evident  to  me 
that  the  mode  of  reduction  by  pressure  made  at  the  fimdus  was  not 
so  applicable  when  the  uterus  had  already  contracted  to  nearly  its 
natural  size.  As  the  fundus  was  indented  by  pressure,  the  body 
spread  laterally  beyond  the  cervix,  and,  although  it  materially  dilated 
the  neck  by  flattening  it,  the  power  was  lost,  without  influencing  to 
any  extent  the  point  of  constriction.  In  fact,  a  continued  force  from 
the  fundus  in  the  upward  direction  seemed  to  increase  the  difficulty 
by  rolling  in  the  parts  at  the  point  of  inversion.     With  this  view,  I 


CASE.  421 


allowed  the  funrlus  to  drop  into  the  palm  of  my  hand,  and  passing 
the  thumb  and  finger  around  the  mass  as  high  up  as  possible  within 
the  cervix,  as  shown  by  Fig.  77,  I  continued  to  enlarge  the  space 
between  the  neck  and  inverted  body,  by  forcibly  expanding  the  fingers 
as  much  as  possible.  At  the  same  time  I  made  steady  upward  pres- 
sure with  a  vicAV  of  returning  first  the  portion  last  involved.     This 


Fi". 


Author's  mode  of  reducing  an  inverted  uterus. 

manoeuvre  was  aided  by  lifting  the  organ  above  the  pubes,  and  en- 
deavoring, with  the  other  hand,  to  roll  out  the  inverted  portion  by 
sliding  the  abdominal  wall  over  the  point  with  some  pressure  (see 
Fig.  77).  In  the  course  of  half  an  hour,  the  progress  of  the  reduction 
was  marked.  The  globular  mass  which  was  felt  through  the  abdomi- 
nal parietes  in  the  beginning  now  gradually  became  oval  laterally, 
with  a  marked  depression  in  the  centre.  By  this  time  my  hand  had 
become  almost  powerless,  and  I  Avas  obliged  to  call  on  Dr.  Elliot  to 
relieve  me  for  a  few  moments  ;  I  then  continued  the  manipulation  for 
some  three-quarters  of  an  hour  longer,  when  Dr.  Thomas,  who  had 
been  absent  during  the  previous  hour,  returned.  From  his  apprecia- 
tion of  the  progress  made,  the  only  fear  I  entertained  of  final  success 
was  a  failure  of  the  patient's  power  of  endurance.  Gradually  the 
fundus  passed  entirely  within  the  cervix,  but  beyond  this  point,  for 
an  hour  longer,  but  little  advance  was  made  in  the  reduction.  The 
depression,  however,  felt  through  the  abdominal  Avails,  above  the  seat 
of  inversion,  had  become  large  enough  apparently  to  admit  the  ex- 
tremities of  three  fingers,  and  there  was  a  proportionate  increase  in 
the  size  of  the  mass.    During  the  whole  time  the  patient  was  kept  pro- 


422  INVERSION  OF  THE  UTERUS. 

foundly  etherized  by  Dr.  Perry.  This  was  found  necessary  from  the 
fact  that  in  the  beginning,  Avhen  its  influence  was  lessened  to  any 
degree,  vomiting  came  on  immediately,  and  with  any  movement  of 
the  patient  it  was  impossible  to  steady  the  uterus  or  maintain  the 
necessary  amount  of  pressure.  The  pulse  had  continued  good  through- 
out, and  her  general  appearance  Avas  satisfactory.  Shortly  before 
four  o'clock  she  began  to  fail;  at  ten  minutes  after  that  hour  her 
condition  had  become  critical,  and  I  was  obliged  to  abandon  my 
efforts  for  the  time,  in  consequence  of  the  powerless  condition  of  my 
hands.  In  consultation,  the  opinion  was  unanimous  that  it  would 
jeopardize  the  life  of  the  patient  to  continue  the  etherization  longer. 
At  my  request  a  last  effort  was  made,  for  I  Avas  satisfied  that  I  could 
not  be  deceived  in  the  fact  that  the  depression  felt  through  the  abdo- 
men was  slowly  becoming  larger.  Drs.  Sabine  and  Elliot,  after  a 
few  moments,  desisted  from  their  efforts,  as  the  latter  gentleman  had 
advised  a  frequent  change,  so  that,  the  hand  of  each  operator  having 
been  rested,  the  power  exerted  would  be  maintained  in  a  more  uniform 
manner.  Dr.  Thomas,  who  had  been  present  but  a  short  time  since 
the  commencement  of  the  operation,  returned  just  as  we  Avere  desisting. 
He  passed  his  hand  into  the  A^agina,  and,  as  he  describes  it,  dreAV 
doAvn  the  mass  so  as  to  reproduce  the  inversion,  and,  on  immediately 
returning  it,  found  that  it  did  so  beyond  its  previous  position ;  he 
repeated  this  manoeavre,  and  on  returning  it,  on  the  point  of  his 
finger  (Avithout  force  on  his  part,  as  he  stated),  the  fundus  passed  on, 
and  the  reduction  Avas  completed,  after  an  effort  of  three  hours  and 
fifty-five  minutes.  During  at  least  three  hours  and  a  half  of  this 
time  I  was  attempting  the  reduction  with  either  the  one  or  the  other 
of  my  hands  in  the  A'agina. 

The  patient  speedily  recovered  consciousness.  During  the  vomit- 
ing, as  a  precaution,  I  passed  the  index  finger  directly  into  the  relaxed 
canal  of  the  uterus  Avhich  Avas  presenting  immediately  Avithin  the  labia. 
It  Avas  fortunate  that  I  did  so,  for  on  the  instant  I  felt  a  portion  of 
the  posterior  Avail,  near  the  fundus,  become  indented.  With  the  other 
hand  on  the  abdomen,  I  seized  the  organ  and  restored  the  portion  on 
the  point  of  my  finger,  and  retained  it  in  the  canal  until  the  parox- 
ysm had  passed.  It  AA'as  the  only  effort  at  vomiting,  and  thei-e  Avas 
no  return  of  the  inversion. 

At  5  P.  M.,  with  a  pulse  of  130,  tAventy-five  drops  of  Magendie's 
solution  of  morphia  were  administered,  Avith  beef-tea,  by  the  mouth. 
At  9  P.  M.,  pulse  128,  as  she  Avas  suffering  from  pain  generally  over 
the  abdomen,  thirty  drops  of  Magendie's  solution  Avere  again  given. 
She  Avas  sleeping  quietly  at  10.80  P.  M. ;  pulse  112  per  minute.  At 
midnight  the  pulse  Avas  108,  and  she  had  been  sleeping  since  the  last 
visit. 

Oct.  11.  At  9  A.M.  the  pulse  Avas  110  ;  she  Avas  free  from  pain, 
and  had  passed  a  quiet  night.  As  there  Avas  some  tenderness  on 
pressure  over  the  abdomen,  a  large  poultice  Avas  ordered.  At  noon 
her  condition  Avas  comfortable,  but  the  pulse  was  120,  with  some 
increase  of  tenderness  over  the  abdomen ;  ordered  the  morphine  to  be 


CASE.  423 

repeated.  Half-past  2  P.  M.,  she  was  free  from  pain  and  sleeping 
quietly,  with  the  pulse  105.  At  7  o'clock  P.  M.  the  pulse  was  the 
same  ;  repeated  the  morphia. 

12th,  9  A.  M.  Pulse  100 ;  she  was  entirely  free  from  pain,  and 
had  passed  a  very  comfortable  night.  From  this  time  she  was  kept 
quiet  in  bed  for  twelve  days,  and  no  further  treatment  was  neces- 
sary. November  28  she  visited  me,  after  taking  a  long  drive.  I 
found  that  the  uterus  had  returned  nearly  to  its  normal  size.  She 
had  menstruated  naturally  a  few  days  before,  and  was  rapidly  regaining 
her  strength  and  flesh. 

This  lady  has  recently  died,  I  learn,  from  an  attack  of  pneumonia. 
She  lived  some  twelve  years  after  the  operation,  and  in  that  time  gave 
birth  to  five  children,  all  in  natural  labors. 

On  presenting  this  case  to  the  Obstetrical  Society,  I  claimed  that 
the  point  was  one  of  great  interest  and  worthy  of  discussion,  as  to 
what  bearing  the  manoeuvre,  as  practised  by  Dr.  Thomas,  had  on  the 
result,  and,  if  effective,  to  determine  the  exact  circumstances  under 
w^hich  it  should  be  resorted  to.  My  own  impression  was  expressed  to 
the  effect  that  Dr.  Thomas  was  mistaken  as  to  the  extent  of  inversion 
reproduced  by  him.  The  portion  below  the  constriction  was  flaccid,  and 
could  be  readily  drawn  down,  but  above  the  engaging  point,  where 
the  surfaces  were  forced  into  such  close  proximity,  it  was  a  question 
Avhether  more  force  would  not  have  been  requisite  to  reproduce  the 
condition  existing  at  the  beginning  than  it  was  possible  to  have  exerted. 
Dr.  Thomas's  effort,  doubtless,  hastened  the  issue,  yet  as  the  widest 
portion  of  the  uterus  was  already  so  far  advanced  within  the  canal,  it 
was  probable  that  the  unaided  muscular  action  of  the  organ  itself 
might,  at  this  stage,  have  soon  completed  the  reduction,  as,  judging 
from  the  result,  the  canal  was  evidently  already  dilated  sufficiently 
for  the  purpose.  This  was  demonstrated  on  an  India-rubber  ball 
which  had  been  indented,  and  it  was  shown  that  as  soon  as  restitution 
has  once  commenced  it  rapidly  progresses  to  its  consummation. 

The  paper  was  discussed  at  length  by  Drs.  Elliot,  Noeggerath,  and 
Budd,  and  these  gentlemen  fully  sustained  my  views.  In  fact,  Dr. 
Thomas  himself,  with  great  candor,  stated  that  he  was  satisfied  he  had 
been  mistaken. 

Case  XVII.— Dr.  Gouley,  Feb.  17,  1866,  requested  Dr.  Noegge- 
rath and  myself  to  see  a  case  of  inverted  uterus  under  his  charge  in 
St.  Vincent's  Hospital,  of  this  city.  With  his  permission  I  reported 
the  case,'  as  possessing  additional  interest,  from  the  fact  that  the  re- 
duction was  eSected  by  the  method  proposed  by  myself,  as  described 

'  American  Journal  of  the  Medical  Sciences,  April,  1866. 


424  INVERSION  OF  THE  UTERUS. 

in  the  preceding  case.  The  patient  was  about  24  years  of  age.  In 
the  preceding  June,  at  full  term,  and  in  perfect  health,  she  was  de- 
livered of  her  second  child  by  a  very  rapid  labor,  in  which  she  had 
but  one  severe  expulsive  pain,  and  that  just  as  the  head  was  expelled. 
Until  a  few  moments  previous  to  delivery,  she  had  not  found  it  neces- 
sary to  lie  doAvn.  The  after-pains  came  on  at  once,  they  were  severe, 
and  lasted  longer  than  had  been  the  case  after  the  birth  of  her  pre- 
vious child.  From  a  short  time  after  delivery  until  the  reduction, 
there  had  been  a  constant  show,  which  frequendy  amounted  to  hemor- 
rhage, and  she  presented  the  appearance  of  one  who  had  been  suffering 
from  an  excessive  loss  of  blood.  Her  condition  had  been  attributed 
to  the  existence  of  a  polypus,  which  was  supposed  to  be  protruding 
from  the  os  uteri,  and  she  had  been  sent  to  the  hospital  to  have  it 
removed. 

After  she  had  been  gotten  under  ether.  Dr.  Gouley,  as  well  as  Dr. 
Wm.  H.  A^an  Buren,  concurred  in  the  diagnosis  formed  by  Dr.  Xoegge- 
rath  and  myself.  At  my  request,  Dr.  Xoeggerath,  following  Dr. 
Gouley,  attempted  the  reduction  by  his  method  of  depressing  one  side 
of  the"^  fundus  into  the  canal  and  carrying  this  portion  up  first,  as  has 
been  described.  After  an  attempt  of  some  fifteen  minutes,  he  found 
it  impossible  to  indent  the  body  sufficiently,  and  desisted.  I  passed 
mv  hand  into  the  vagina,  and  for  a  while  endeavored  to  put  his  method 
into  practice,  but  found  it  impossible  to  produce  any  real  effect.  In 
fact,  the  organ  was  so  dense,  and  contracted  to  so  nearly  its  natural 
size,  that  the  case  was  not  a  fair  one  in  which  to  test  his  mode,  nor 
was  the  inversion  one  which  could  have  been  reduced  by  pressure  at 
the  fundus,  as  proposed  by  Prof.  White,  while  it  Avas  in  every  respect 
favorable  to  the  method  I  resorted  to.  I  passed  my  fingers  around 
the  portion  within  the  os  as  described  in  the  previous  case.  Then,  with 
a  simultaneous  upwai-d  and  outward  pressure,  the  neck  was  gradually 
dilated,  until,  by  a  forcible  extension  of  the  fingers,  the  seat  of 
inversion  Avas  reached.  In  less  than  half  an  hour  the  mass,  as  felt 
through  the  abdominal  parietes,  had  doubled  in  size,  the  depression 
in  the  centre  had  become  larger,  and  the  shape  had  changed  from  a 
circle  to  an  oval.  The  fundus  gradually  passed  entirely  within  the 
cervix,  but,  after  this,  the  progress,  as  appreciated  by  the  fingers 
Avithin  the  uterus,  was  almost  imperceptible,  though  the  rapidly  in- 
creasing size  of  the  mass  and  diameter  of  the  depression,  at  the  seat 
of  inversion,  was  recognized  by  all  present.  At  the  end  of  an  hour, 
mv  hand  in  the  vagina  became  so  poAverless  that,  Avithout  the  aid  of 
the  hand  over  the  abdomen,  I  Avas  unable  to  feel  the  body  of  the 
uterus  within  its  grasp.  I  finally  retpiested  Dr.  Xoeggerath  to  relieve 
me,  and,  by  his  continued  manipulation,  in  about  ten  minutes  the  re- 
duction Avas  completed,  after  a  conjoined  effort  of  an  hour  and  twenty 
minutes. 

This  Avoman  had  .a  rapid  recovery,  but  I  have  known  nothing  of  her 
history  subsequent  to  her  leaving  the  hospital. 


CASE.  425 

Case  XVIII. ^ — Mrs.  C,  aged  26,  on  the  recommendation  of  Dr. 
Crispell,  of  Rondout,  N.  Y.,  was  admitted  to  my  private  hospital. 
May  21, 18GT,  and  presented  the  following  history.  She  menstruated 
first  at  12  years  of  age,  married  at  28,  and  had  heen  in  perfect 
health  previous  to  the  birth  of  her  child.  Labor  at  full  term  com- 
menced Dec.  22,  1865,  and  was  terminated  without  artificial  aid  at 
the  end  of  twenty  hours,  its  progress  having  been  somewhat  tedious, 
but  otherwise  natural.  By  the  next  pain  following  the  birth,  the 
placenta  was  expelled,  without  traction  or  any  interference.  The  cord 
was  of  a  natural  length,  and  not  looped  about  the  body  of  the  child. 
She  was  attended  by  a  physician  of  experience,  who  furnished  Dr. 
Crispell  with  the  following  interesting  features  of  the  case.  Before 
putting  on  the  bandage  he  waited  some  time,  and  satrsfied  himself  that 
the  uterus  had  properly  contracted.  As  he  was  leaving  the  house  he 
heaixl  her  bearing  down  as  with  an  expulsive  pain,  but  feeling  satisfied 
that  there  could  be  nothing  unusual  in  her  condition,  he  proceeded  to 
his  home,  but  a  few  hundred  yards  distant.  He,  however,  felt  uneasy, 
and  on  his  almost  immediate  return  he  found  that  he  was  just  being 
sent  for,  and  that  there  had  been  hemorrhage  and  violent  and  con- 
tinuous pain  ever  since  his  departure.  An  examination  disclosed  a 
complete  inversion  of  the  uterus,  which  he  immediately  reduced  with- 
out difficulty,  and,  with  the  recurrence  of  pain,  the  organ  contracted 
naturally.  He  remained  in  the  house  for  nearly  three-quarters  of  an 
hour  afterwards,  and,  before  leaving,  satisfied  himself  that  the  uterus 
had  properly  contracted.  The  after-pains  were  slight,  she  made  a 
good  recovery,  nursed  her  child,  and  was  apparently  in  perfect  health 
until  thirteen  months  afterwards.  Menstruation  then  returned,  and, 
at  the  end  of  five  days,  when  it  had  nearly  ceased,  excessive  hemor- 
rhage suddenly  came  on.  The  uterus  was  then  found  completely  in- 
verted, and  the  fundus  just  within  the  labia.  By  astringent  injections 
the  hemorrhage  was  for  the  time  arrested.  At  the  end  of  the  fifth 
day  of  the  next  menstrual  period,  the  hemorrhage  again  occurred, 
and  with  each  period  afterwards  would  continue  until  arrested  by 
astringents  or  the  tampon.  She  was  exceedingly  aneemic,  and  had 
at  all  times  a  profuse  watery  discharge,  with  a  tendency  to  hemor- 
rhage on  the  least  exertion. 

A  few  days  after  her  admission,  with  a  pulse  of  120,  she  was  placed 
under  ether,  and  I  attempted  the  reduction.  Drs.  Peaslee,  Crispell, 
and  Perry  were  present.  The  condition  of  the  uterus  was  remarkable, 
and  it  might  easily  have  been  mistaken  for  a  polypus.  The  vagina 
was  found  occupied  by  a  soft,  smooth  mass  about  the  size  of  a  hen's 
egg,  with  a  distinct  pedicle  scarcely  three-quarters  of  an  inch  in 
diameter,  around  which  the  cervix  was  well  contracted.  The  uterine 
probe  passed  a  little  over  tAvo  inches  into  the  canal,  and  apparently  to 
the  fundus.  The  left  hand  was  introduced  into  the  vagina,  and  the 
other  above  the  pubes,  they  were  then  approximated  sufficiently 
behind  the  uterus  to  indicate  that  the  case  was  one  of  inversion, 

'  The  American  Journal  of  the  Medical  Sciences,  Jan.  18()8. 


426  INVERSION  OF  THE  UTERUS. 

while  from  the  shape  of  the  mass  and  the  depression  in  its  centre,  felt 
through  the  abdominal  wall,  there  remained  no  question  as  to  the 
true  condition.  Half  an  hour  after  commencing  the  reduction,  by 
the  method  described,  the  cervix  and  canal  had  become  so  dilated  that 
the  fundus  could  be  carried  entirely  within  the  uterine  cavity,  but 
beyond  this  no  progress  could  be  made  in  the  reduction.  The  pedun- 
culated portion  was  so  small  that  it  would  double  on  itself  in  such  a 
manner  that  the  upward  force,  of  so  much  importance  at  this  stage, 
could  not  be  fully  exerted,  and  was  lost  to  a  great  extent.  Over  the 
edge  of  the  ring,  formed  by  a  portion  which  had  been  inverted  and 
now  but  just  rolled  out,  the  broad  ligament  on  the  right  side  was  felt 
thickened  and  dipping  into  the  canal  formed  by  the  inversion.  On 
turning  the  uterus  up  against  the  abdominal  wall,  by  means  of  the 
hand  in  the  vagina,  this  condition  was  recognized  by  all  present,  and 
as  the  mass  could  not  be  moved  aside,  it  Avas  feared  that  adhesions 
existed  to  an  extent  which  could  not  be  overcome.  It  was  also  thought 
that  this  had  given  rise  to  some  impediment  to  the  circulation,  and 
thus  brought  about  an  atrophied  condition  of  the  body  of  the  organ. 
At  the  end  of  three  hours  the  condition  of  the  patient  became  so  feeble 
that  all  further  attempts  at  reduction  were  for  the  time  abandoned. 

June  19.  Ether  was  again  administered,  the  pulse  being  feeble, 
and  140  per  minute.  Drs.  Peaslee,  Clymer,  Crispell,  and  Perry  were 
present.  Notwithstanding  that  the  original  condition  of  the  inversion 
had  returned,  in  less  than  half  an  hour  all  was  gained  that  had  been 
accomplished  by  the  previous  effort.  At  the  end  of  the  first  hour  the 
pedunculated  part  of  the  body  had  disappeared,  and  the  ring  at  the 
seat  of  the  inversion  had  become  so  dilated  that,  by  pushing  up  through 
it  a  portion  on  the  right  side,  the  finger  was  distinctly  felt  through 
the  abdomhial  wall  by  the  gentlemen  present.  It  was  now  evident 
that  the  broad  ligament,  in  a  mass,  was  firmly  adherent,  and  that  the 
reduction  could  not  be  accomplished  unless  the  ring  at  the  seat  of 
inversion  could  be  dilated  sufficiently  to  admit  of  the  left  side  of  the 
uterus  being  reduced  first,  and  afterwards  the  opposite  side  by  rotat- 
ing it  bodily  around  through  the  dilated  portion,  thus  leaving  the 
adhesions  intact.  But  to  accomplish  this  extent  of  dilatation  was 
almost  beyond  the  expanding  capacity  of  the  fingers.  I  continued, 
however,  my  efforts  for  five  hours,  occasionally  being  assisted,  towards 
the  close,  by  Drs.  Peaslee  and  Perry,  but  no  progress  was  made  after 
the  first  hour,  except  to  dilate  gradually  the  portion  below  the  seat 
of  inversion  to  such  an  extent  that  the  cervix  and  uterine  canal  became 
lost  almost  as  one  continuous  cavity  with  the  vagina.  During  the  last 
hour  the  circulation  became. so  irregular  and  feeble  that  the  anaesthetic 
had  to  be  abandoned,  and  stimulants,  as  well  as  beef-tea,  freely  re- 
sorted to.  At  length  I  was  reluctantly  forced  to  cease  my  efforts  for 
the  time,  but  I  was  determined  to  make  another  attempt,  and  not 
■wishing  to  lose  what  had  already  been  gained,  I  introduced  rapidly 
five  deep  interrupted  silver  sutures  into  the  neck  of  the  uterus,  and 
on  twisting  them  drew  the  sides  of  the  cervix  together  over  the  fundus, 
thus  confining  it  within  the  uterine  canal,  like  a  ball  within  its  cover. 


CASE.  427 

This  was  clone  on  Wednesday  ;  she  soon  rallied,  and  within  twelve  hours 
had  regained  her  usual  condition,  still  full  of  hope  and  not  discouraged 
by  the  failure.  She  was  kept  in  bed,  and  on  the  following  Satur- 
day, about  noon,  she  felt  something  suddenly  slip,  as  she  expressed 
it,  with  immediate  relief  from  a  feeling  of  fulness  Avhich  she  had  ex- 
perienced since  the  operation.  My  impression  at  once  was  that  the 
sutures  had  torn  out,  or  possibly  that  the  uterus  had  become  reduced, 
but  on  examination  the  sutures  were  found  intact,  and  on  passing  the 
sound  between  them  the  fundus  was  felt  behind.  I  now  became 
satisfied  that  the  adhesions  above  had  separated,  and  that  I  could 
almost  promise  success  from  the  next  effort  at  reduction.  In  case  of 
failure,  however,  I  determined  to  freshen  the  edges  of  the  cervix, 
reintroduce  the  sutures,  and,  by  uniting  the  parts  permanently,  to 
confine  the  fundus  within  the  uterine  canal. 

On  the  following  Wednesday,  a  week  after  the  previous  attempt, 
ether  was  again  administered  and  the  sutures  removed.  The  fundus 
immediately  dropped  into  the  vagina,  while  the  extent  of  dilatation 
was  about  the  same  as  had  been  gained  on  each  previous  attempt  at 
the  end  of  the  first  half  hour,  but  the  mass  above,  supposed  to  have 
been  the  broad  ligament,  had  disappeared.  After  she  had  been  ex- 
amined by  the  gentlemen,  in  twenty-seven  minutes  from  the  time  my 
hand  was  introduced  into  the  vagina,  about  five  minutes  of  which  time 
Avere  occupied  in  ascertaining  her  condition,  I  reduced  the  inverted 
organ  unaided.  Drs.  Clymer  and  Perry  were  present  at  the  time  of 
reduction ;  Dr.  Peaslee  was  also  at  the  beginning,  but  Avas  obliged  to 
leave  to  see  a  patient,  intending  to  return  to  aid  me  afterwards.  The 
effect  of  the  reduction  on  the  circulation  was  remarkable,  for,  within 
half  an  hour  afterwards,  the  heart's  action  became  regular,  and  the 
pulse  fell  from  150  to  90  beats  per  minute.  Her  whole  appearance 
was  improved,  and  her  lips,  which  had  been  previously  bloodless, 
became  of  a  natural  color.  Not  a  bad  symptom  supervened  ;  she  sat 
lip  at  the  end  of  a  week,  and  returned  home  early  in  July. 

Mrs.  C.  soon  regained  her  usual  health,  but  became  sterile.  I  made 
an  examination  several  years  after  the  reduction,  but  found  no  special 
lesion  beyond  a  partial  double  laceration  of  the  cervix,  which  did  not 
allow  the  parts  to  roll  out  sufficiently  to  necessitate  an  operation. 

An  interesting  point  in  this  case  is  to  determine  at  what  time  after 
labor  the  inversion  was  reproduced.  Mrs.  C.  for  a  year  after  her 
confinement  was  apparently  in  perfect  health,  and  led  an  active  life, 
while  neither  she  nor  her  husband  was  aware  of  a  condition  which, 
in  a  marital  relation,  Avould  have  amounted  to  a  positive  obstruction 
had  the  inversion  existed  to  the  extent  found  at  my  first  examination. 
After  the  fifth  day  of  the  first  menstrual  period,  she  was  never  free 
from  backache,  nor  from  a  profuse  watery  discharge,  until  after  the 
fundus  was  secured  by  closing  the  cervix;  she  was  also  liable  to 
hemorrhage  on  making  the  slightest  exertion.     The  attending  physi- 


428  INVERSION  OF  THE  UTERUS. 

cian  satisfied  himself,  as  has  been  stated,  that  the  uterus  contracted 
properly  after  he  restored  the  organ,  and  I  have  been  assured,  from 
his  professional  standing,  that  he  could  scarcely  have  been  deceived 
on  this  point.  Nor  is  there  any  evidence  that  he  may  have  been 
mistaken,  for  the  symptoms  of  inversion  are  generally  unmistakable 
immediately  on  the  occurrence  of  the  accident.  Is  it  possible  that 
nursing  the  child  could  have  exerted  an  influence  to  the  extent  of 
keeping  in  abeyance,  as  it  were,  every  symptom  of  this  condition,  if 
it  existed,  during  the  year  after  her  delivery  ?  And  yet,  while  the 
first  menstrual  period  was  painful,  it  was  not  more  so  than  had  been 
frequently  the  case  before  pregnancy,  nor  was  it  increased  in  intensity 
at  any  time,  from  confinement  to  the  first  return  of  the  menses,  so 
that  no  indication  is  offered  of  the  moment  when  the  inversion  pro- 
bably occurred.  From  the  data  presented  in  the  case,  I  confess 
myself  entirely  at  a  loss  to  offer  even  a  speculation  on  the  subject. 

Case  XIX. ^ — Mrs.  Conklin,  aged  54,  was  admitted  to  the  Woman's 
Hospital  April  19,  1869,  with  the  following  history :  Her  general 
health  during  childhood  had  been  delicate,  and  at  the  approach  of  a 
retarded  puberty  she  suffered  from  frequent  attacks  of  fainting,  with 
great  nervous  prostration.  She  menstruated  for  the  first  time  at 
eighteen,  but  never  became  regular.  It  was  her  impression  that  the 
flow  had  been  from  the  first  unusually  painful,  too  frequent,  and  pro- 
fuse. She  married  at  thirty-five,  and  remained  sterile.  During  her 
married  life  the  menstrual  flow  became  more  painful  and  irregular, 
while  at  times  she  was  not  free  from  a  show  for  more  than  three  or 
four  days  in  each  month.  During  the  same  period,  until  a  change  of 
life  took  place  at  the  age  of  fifty,  she  suffered  almost  constantly  from 
a  dragging  pain  in  the  back  and  about  the  hips.  After  the  menstrual 
cessation  her  general  health  improved  and  continued  to  do  so  for  two 
years.  During  February,  1867,  she  contracted  a  severe  cold,  and 
while  in  the  midst  of  a  paroxysm  of  coughing  she  suddenly  experienced 
a  feeling  of  great  discomfort  in  the  vagina,  accompanied  by  pain  in 
the  back  and  hips,  which  could  not  be  localized.  Her  suffering  be- 
came so  urgent  that  she  was  obliged  to  seek  i;elief  from  her  physician. 
A  vaginal  examination  was  not,  however,  deemed  necessary,  but  from 
the  symptoms  her  suffei'ing  was  attributed  to  "falling  of  the  womb," 
for  Avhich  the  recumbent  position  and  astringent  injections  were  pre- 
scribed. Since  she  did  not  obtain  relief  by  these  means,  she  made  a 
digital  examination  and  found  the  vagina  obstructed  near  the  outlet 
by  a  mass  which  was  not  there  a  short  time  previous.  She  remained 
an  invalid,  unable  to  stand  or  exercise,  with  a  constant  vaginal  dis- 
charge for  fourteen  months  previous  to  her  admission  to  the  hospital. 

On  examination,  the  uterus  Avas  found  inverted,  with  a  fibro-cystic 

'  The  American  Journal  of  Obstetrics,  August,  18G9. 


CASE. 


429 


tumor  situated  at  the  fundus,  which  presented  just  within  the  labia. 
As  will  be  seen  by  reference  to  the  plate,  the  uterus  was  completely 
inverted  on  the  left,  Avhile  on  the  other  side  the  line  of  the  shortened 
cervix  was  defined  by  a  shallow  crescentic-shaped  sulcus.  The  uterus 
Avas  an  inch  and  three-quarters  in  length,  from  the  bottom  of  this  fold 
to  the  attachment  of  the  tumor  at  the  fundus.  The  tumor  Avas  as  large 
as  a  pigeon's  egg  (see  Fig.  78),  but  had  evidently  undergone  a  re- 

Fiff.  78. 


laverted  uterus,  with  libro-cystic'tumor.     (Speculum  in  situ.) 

duction  in  size  from  cystic  degeneration.  Several  large  cysts  exist- 
ing within  the  mass  were  prominent,  while  on  the  surface  were  several 
cicatricial  depressions,  evidently  the  traces  of  other  cysts  which,  in 
being  emptied,  had  brought  about  a  diminution  in  the  size  of  the 
tumor.  The  mucous  surface  of  the  uterus  was  of  a  pale  color,  present- 
ing in  fact  the  same  appearance  as  that  of  the  vagina,  and  did  not  bleed 
on  being  handled.  The  arborescent  configuration  of  its  surface  was 
well  marked,  and  on  the  right  side  the  shrivelled  remains  of  a  mucous 
polypus  existed.  The  diagnosis,  as  to  the  condition  of  the  uterus, 
was  proved  by  passing  the  index  finger  into  the  rectum,  so  as  to 
approximate  the  extremity  of  a  sound  felt  within  the  bladder  at  a 
point  just  above  the  mass  in  the  vagina,  it  being  evident  at  the  same 
time  that  nothing  existed  above  the  plane  of  the  vaginal  junction 
which  could  be  mistaken  for  the  body  of  the  uterus. 

May  4.  A  consultation  was  called,  ether  was  administered,  and 
the  condition  verified  by  Dr.  George  T.  Elliot,  one  of  the  Consulting 
Eoard,  and  Drs.  G.  C.  Nott,  Trask,  Swift,  Perry,  and  others  present. 


430  INVERSION  OF  THE  UTERUS. 

The  ^craseur  was  applied,  and  the  tumor  removed  from  the  fundus 
with  but  little  bleeding  afterwards.  It  was  then  determined  to  intro- 
duce the  hand  into  the  vagina,  and  to  reduce  the  inversion  by  the 
method  Ave  have  been  describing  for  the  previous  cases.  It  was  found, 
however,  impossible  to  introduce  the  hand,  as  the  patient  was  obese, 
and  had  a  short  and  narrow  vagina,  the  result  of  a  change  of  life. 
The  uterus  was  therefore  drawn  down  to  the  vulva,  and  the  organ 
steadied  bj  seizing  the  edge  of  the  cervix  on  each  side  with  a  tenacvi- 
lum  held  by  an  assistant.  With  the  uterus  thus  fixed,  a  portion  in 
advance  of  the  vaginal  junction  was  grasped  between  the  thumb  and 
forefinger  of  the  right  hand,  while  a  steady  upward  pressure  was  made 
uatil  the  os  uteri  became  well  defined.  The  cervix  was  then  dilated 
by  passing  the  index  finger  around  at  the  bottom  of  the  sulcus,  be- 
tween the  neck  and  inverted  body  of  the  uterus,  while  at  the  same 
time  a  steady  upward  pressure  was  maintained  by  the  finger.  When 
the  fore-finger  became  fatigued,  the  body  was  seized  with  the  fingers 
as  in  the  beginning,  and  the  upward  pressure  exerted,  while  the  index 
finger  of  the  other  hand  was  passed  into  the  rectum  behind  the  organ, 
to  relieve  the  strain  on  the  tenacula,  which  were  frequently  tearing 
out.  After  three-quarters  of  an  hour,  the  fundus  passed  within  the 
OS  uteri.  After  persevering  an  hour  longer,  it  had  advanced  above 
the  plane  of  the  vaginal  junction,  so  that  a  sound  could  be  passed 
within  the  cavity  a  little  over  an  inch.  From  this  time  no  advance 
was  made,  and  attributing  it  to  the  fact  that  my  fingers  had  become 
too  cramped  for  eff'ective  service,  I  obtained  Dr.  Elliot's  aid,  but 
Avithout  his  being  able  to  make  any  apparent  change.  It  now  became 
evident  that  attempt  at  further  reduction  Avould  have  to  be  abandoned  on 
account  of  the  condition  of  the  patient,  and  the  certainty  of  adhesions, 
as  suggested  by  Dr.  Nott.  This  view  was  strengthened  after  a  careful 
digital  examination  per  rectum.  It  was  found  that  the  depression 
which  had  been  felt  at  the  seat  of  inversion,  before  attempting  the 
reduction,  had  nearly  disappeared,  while  in  fact  it  should  have  been 
enlarged  as  the  reduction  advanced.  Although  the  exact  condition 
could  not  be  defined.  Dr.  Nott's  explanation  seemed  to  be  the  true 
one,  that  some  portion  of  the  broad  ligament  had  become  adherent  on 
both  sides,  and  when  the  reduction  had  advanced  so  far  as  to  roll  out 
these  surfaces  to  a  certain  point,  no  further  advance  could  be  made 
unless  a  separation  could  be  brought  about  on  one  side  at  least. 
The  patient  had  been  suffering  from  a  catarrh  previous  to  the  opera- 
tion, so  that  it  became  necessary  to  desist  in  consequence  of  great 
irritability  of  the  air  passages  produced  by  so  long  a  continuance  of 
the  ether. 

As  in  the  previous  and  similar  case  Avhere  adhesions  existed,  and 
the  procedure  had  proved  successful  in  striping  them  oif,  I  introduced 
three  deep  interrupted  silver  sutures  into  the  cervix.  On  twisting 
these,  the  sides  of  the  oa,  in  the  middle,  were  brought  together  over 
the  fundus.  Thus  the  exercise  of  a  steady  force  was  kept  up,  well 
calculated,  as  we  shall  see,  for  gradually  overcoming  any  adhesions 
which  were  not  of  too  firm  a  charact(;r.     Moreover,  the   advance 


CASE.  431 

already  made  Avas  thus  secured,  so  that  the  reduction  could  be  again 
attempted  under  more  favorable  circumstances  if  deemed  advisable. 
She  reacted  badly  from  the  effects  of  the  ether,  vomiting  afterwards, 
and  suffered  from  a  severe  attack  of  bronchitis.  On  the  seventh  day 
the  sutures  were  removed,  and,  as  the  general  condition  of  the  patient 
would  not  admit  of  further  interference,  no  attempt  was  made  to  com- 
plete the  reduction.  The  fundus  still  remained  within  the  canal  after 
the  withdrawal  of  the  sutures,  but  as  she  was  suffering  from  a  con- 
stant cough  it  was  fully  expected  that  the  inversion  would  again  be- 
come complete.  On  the  21th  day  after  the  operation,  she  returned 
home  to  recruit,  but  before  doing  so  an  examination  was  made,  Avhen 
it  was  found  to  my  surprise  and  satisfaction  that  no  descent  of  the 
fundus  had  taken  place. 

June  15.  She  returned  to  the  hospital  having  recovered  her  health, 
and  was  able  to  walk  or  stand  without  the  least  inconvenience. 

l^th.  In  the  presence  of  Drs.  Nott,  Trask,  Prof.  John  S.  Davis  of 
the  University  of  Va.,  and  others,  I  denuded  a  portion  of  the  inner 
face  of  the  os  uteri,  and,  after  introducing  three  deep  interrupted 
silver  sutures,  brought  the  sides  together  in  the  centre,  leaving  the 
line  open  at  each  extremity.  Notwithstanding  the  fundus  had  not 
descended,  and  the  canal  remained  of  the  same  depth  as  after  the 
attempt  at  reduction  had  been  abandoned,  it  was  decided  best  to 
partially  close  the  os  for  fear  that  by  accident  the  inversion  might  be 
again  produced.  It  was  not  deemed  necessary  to  made  a  second 
attempt  at  the  reduction,  from  the  fact  that  the  existence  of  firm 
adhesions  seemed  proved  by  the  fundus  remaining  in  the  same  position, 
after  the  support  given  by  the  sutures  had  been  withdrawn.  More- 
over, her  age  did  not  make  it  so  necessary  to  persevere,  and  she  was 
unwilling  to  take  ether  again,  and  without  this  but  little  could  be 
accomplished.  The  sutures  Avere  removed  on  the  eighth  day,  the 
union  was  found  perfect,  and  shortly  afterwards  she  was  discharged 
from  the  hospital.  Five  years  after  I  ascertained  through  a  friend 
that  she  was  in  good  health. 

A  similar  case  of  inversion  of  the  uterus,  caused  by  a  tumor  at 
the  fundus,  is  reported  by  Dr.  Alfred  H.  McClintock  in  his  "Clinical 
Memoirs  on  Diseases  of  Women,"  page  97.  Other  cases  are  on  record, 
but  all,  with  the  exception  of  these,  had  borne  children,  so  far  as  my 
knowledge  extends. 

I  believe  that  the  procedure  resorted  to  in  these  cases,  of  confining 
the  fundus  within  the  uterine  canal,  will  prove  to  be  of  the  greatest 
practical  importance.  Where,  from  any  cause,  the  attempt  at  reduc- 
tion has  to  be  abandoned  for  the  time,  an  extensive  amount  of  dilata- 
tion is  thus  preserved  until  the  condition  of  the  patient  will  admit  of 
another  effort  for  her  relief.  On  a  moment's  reflection,  it  will  be 
evident  that  a  persistent  dilating  force  is  at  once  established,  Avithout 
taxing  the  strength  of  the  patient,  which  may  of  itself,  in  some  cases, 


432 


INVERSION    OF    THE    UTERUS. 


complete  the  reduction  unaided.  By  stretching  the  cervix  over  the 
fundus,  an  unyielding  mass  within  the  uterine  canal,  a  force  is  exerted 
on  the  outside  of  the  organ  to  roll  out  the  parts  above,  while,  at  the 
same  time,  an  upward  action  is  at  once  established  below  the  inversion, 
by  forcing  the  fundus  as  a  wedge  in  the  direction  offering  the  least 
resistance.  Then,  any  action  of  either  the  longitudinal  or  circular 
fibres  of  the  uterus,  or  both  together,  will  aid  in  the  reduction.  By 
reference  to  diagram.  Fig.  79,  the  action  of  these  forces  will  be  seen 
indicated  by  the  direction  of  the  arrow-heads. 

Fig.  79. 


wewmL 


Diagram  showing  direction  of  traction  exerted  by  sutures  in  cervix  uteri 
after  partial  reduction  of  inversion. 

That  this  force  did  not  succeed  in  completing  the  reduction  in  one  of 
the  cases  (Case  XVIII.),  Avas  due,  I  believe,  to  the  singularly  peduncu- 
lated condition  of  the  body.  But  that  the  force  was  exerted  to  a  great 
degree,  is  proved  by  the  fact  that  the  adhesions  of  the  broad  ligament 
where  put  on  the  stretch  were  separated  by  its  action,  although  I  had 
been  unable  to  accomplish  so  much  after  a  continuous  eflfort  of  four 
hours.  It  requires,  as  a  rule,  but  little  time  and  patience  to  dilate 
fully  the  cervix  and  uterine  canal  by  the  method  I  have  proposed. 
Tlien,  if  the  operation  cannot  be  completed  at  the  time,  the  fundus 
can  be  secured,  and  the  same  continuous  force  will  be  maintained 
without  danger  to  the  patient.     The  power  exerted  is  exactly  that 


CLOSING    THE    OS.  433 

brought  to  bear  on  the  uterus  Avhcn  the  vagina  has  been  fully  dis- 
tended by  an  air-bag.  The  fundus  is  crowded  up  into  the  canal,  and 
the  vaginal  walls  being  put  on  the  stretch  aid,  to  some  extent,  in 
pulling  open  the  parts  above  at  the  seat  of  invei'sion.  But  this  plan  is 
not  eftective  unless  the  vagina  be  distended  to  the  utmost.  Then 
great  suifering  is  necessarily  inflicted  on  the  patient,  and  there  is 
risk  always  of  exciting  cellulitis  and  even  peritonitis. 

But  the  point  I  wish  particularly  to  establish  is  the  advantage  of 
closing  the  os  in  cases  Avhere  the  inversion  is  irreducible,  a  condition, 
however,  I  am  not  willing  to  acknowledge  is  possible,  except  under 
some  very  unusual  circumstances.  In  view  of  this,  I  think  it  is 
wholly  unjustifiable  to  amputate  the  inverted  portion  of  the  uterus  if 
the  fundus  can  be  gotten  within  the  cervix. 

For  this  part  of  the  operation  it  is  necessary  to  denude  with  a  pair 
of  scissors  the  inner  edge  of  the  cervix,  and  to  secure  its  surfaces 
by  a  number  of  interrupted  silver  sutures.  Or  the  whipstitch  may 
be  employed,  to  be  introduced  far  back  from  the  edge  and  near  the 
vaginal  junction,  so  as  to  render  it  impossible  for  it  to  cut  out  before 
perfect  union  has  been  obtained.  In  Fig.  79,  Avhich  represents  a 
section  of  the  left  half  of  the  uterus,  the  dotted  lines  show  the 
course  of  a  suture  already  twisted,  but  not  yet  bent  over  flat  to  the 
vaginal  surface.  It  is  not  advisable  that  the  denudation  should  be 
extended  entirely  around  the  cervical  canal,  but  only  so  far  as  will 
insure  an  opening  at  each  angle  of  the  line  for  the  free  escape  of 
the  secretions  and  menstrual  flow.  By  this  operation,  all  hemorrhage 
due  to  the  inversion  will  be  arrested  at  once.  The  patient  will  soon 
recover  her  strength,  and  may  even  become  pregnant,  and  should  this 
occur,  nature  may  be  relied  upon  to  complete  the  reduction.  The 
line  of  union  would  ofier  certainly  but  little  obstruction  to  the 
progress  of  labor,  for  if  separation  did  not  take  place  at  the  proper 
time,  a  pair  of  scissors  could  be  readily  made  to  snip  it  open. 

But  I  would  advise,  before  resorting  to  denudation  for  bringing 
about  permanent  closure  of  the  os,  that  the  suture  alone  be  employed. 
This  would  give  the  opportunity  for  making  another  attempt  at  reduc- 
tion if  nature  failed  to  accomplish  it.  To  test  this  fairly  the  sutures 
should  be  allowed  to  remain  undisturbed  for  weeks  if  they  do  not 
cut  from  too  great  tension.  Their  ends  should  be  bent  over  properly, 
and  made  to  lie  flat  to  the  surface,  according  to  the  directions  which 
have  been  already  given. 
28 


434  INVERSION    OF    THE    UTERUS. 

That  this  plan  of  reduction  has  not  fullj  succeeded  in  the  hands  of 
others  is  due  either  to  the  fact  that  the  different  steps  have  not  been 
understood,  or  that  the  attempt  has  been  made  to  accomplish  too  much 
in  too  short  a  time.     Let  us  briefly  review  the  different  steps  and 
the  principle  involved  in  the  operation.     Bj  a  glance  at  Fig.  77, 
it  will  be  apparent  that  the  surfaces  within  the  neck  cannot  be  sepa- 
rated to  any  extent  without  rolling  out  the  parts  immediately  at 
the  seat  of  inversion.     This  action  must  necessarily,  at  the  same 
time,  pull  open  the  mouth  of  the  canal  now  formed  by  the  external 
surface   of  the   uterus.     Through   this   dilated   canal   the   inverted 
portion   of  the    organ   is   to   be  returned.     Until   the   fundus   has 
passed  well  within  the  cervix,  the  chief  effort  must  be  directed  to 
dilating  the  neck  by  expanding  the  fingers  in  an  upward  and  outward 
direction.     In  other  words,  the  uterus  should  be  firmly  grasped  by 
all  the  fingers  immediately  below  the  seat  of  inversion,  and,  at  the 
instant  before  expanding  the  fingers,  be  pressed  upwards  against  the 
hand  on  the  abdominal  wall.     The  hand  above  should  at  the  same 
moment  be  making  pressure  downward  and  outAvard,  by  sliding  the 
parietes  over  the  portion  within  the  cavity.     The  procedure  must 
be  repeated  in  this  order   until  the  fundus  can  be  passed  entirely 
within  the  cervix.     The  necessity  for  augmenting  this  upward  pres- 
sure increases  in  proportion  to  the  advance  made  in  the  reduction, 
while  the  aid  derived  from  expanding  the  fingers  becomes  proportion- 
ately lessened  to  the  point  of  completion.     There  is  still,  however,  a 
dilating  force  exerted  by  wedging  the  fingers  betAveen  the  prolapsed 
portion  and  the  sides  of  the  canal.     For,  as  the  uterine  canal  is 
enlarged   in  its   lateral   diameter,  the    reduction   is   advanced   pari 
passu  by  shortening  the  vertical  one.     But  no  advance  can  be  gained 
bv  main  force,  for  it  is  impossible,  without  rupture,  for  any  portion 
to  pass  until  the  necessary  dilatation  has  been  effected.     It  is  well 
occasionally  to  alternate  the  pressure   so  that  it  shall  bear  first  to 
one  side  and  then  to  the  other,  instead  of  pressing  the  mass  always 
in  the  same  direction.     Sometimes  it  should  be  a  hand-to-hand  mo- 
tion, as  in  the  delivery  of  the  foetal  head  by  forceps.     On  the  same 
principle  the  vagina,  for  a  moment  or  two  at  a  time,  should  be  placed 
on  the  stretch  by  making  steady  pressure  in  the  dii-ection  of  the 
promontory  of  the  sacrum.     By  thus  changing  the  direction  of  pres- 
sure in  the  last  stage,  a  portion  of  the  mass  will  sometimes  suddenly 
slip  up,  when  a  moment  before  it  seemed  immovable,  from  being  wedged 
in  such  close  apposition.     By  resting  the  back  of  the  hand  in  the 


CLAIMS    FOR    PRIORITY.  435 

hollow  of  the  sacrum,  so  as  to  turn  the  organ  up  against  the  ab- 
dominal wall  above  the  pubes,  the  hand  of  the  operator  is  placed 
in  a  less  constrained  position,  while  at  the  same  time  the  uterus  is 
steadied,  and  the  counter-pressure  exerted  by  the  other  hand  is 
maintained  to  the  best  advantage.  Every  step  is  to  be  gained  by 
a  steady  and  persistent  eifort,  but  without  violence.  Towards  the 
close  of  the  operation  the  advance  of  the  fundus  is  hastened  beyond 
question  by  a  rapid  change  of  assistants,  so  that  the  force  may  be  as 
nearly  continuous  as  possible,  and  not  allowed  to  flag  from  the  fatigue 
which  must  attend  the  prolonged  efforts  of  any  one  person.  We  may 
repeat,  then,  that  too  much  must  not  be  attempted  at  first,  for  until 
the  vagina  has  become  somewhat  dilated,  and  the  hand  of  the  operator 
accustomed  to  the  manipulation,  what  was  accomplished  in  the  begin- 
ning wnll  be  to  a  great  extent  lost,  in  consequence  of  his  hand 
becoming  almost  powerless  from  cramp.  The  operator  must  learn 
to  husband  his  strength  until  the  fundus  can  be  passed  within  the 
cervix,  when  it  can  be  made  available  to  the  greatest  advantage. 
Finally,  so  long  as  the  etherization  is  well  borne  by  the  patient,  no 
case  must  be  despaired  of  in  consequence  of  the  apparent  want  of 
progress,  for  at  any  instant  the  reduction  may  be  suddenly  completed. 

I  have  been  credited  by  Dr.  Thomas,  in  his  valuable  work  on  the 
Diseases  of  Women,  with  reviving  in  the  above  procedure  Viardel's 
method  of  reduction.  This  I  am  not  entitled  to,  nor  does  it  appear 
that  Viardel  had  a  method.  In  the  first  edition  of  this  work,  we  find 
the  following  as  the  best  method  of  reducing  an  inverted  uterus : 
"  1st.  The  method  of  Viardel — dilating  by  the  fingers  the  constricted 
neck,  and  forcing  up  first  the  tissue  which  came  forth  last."  In  the 
second  edition — "  The  first  of  these  methods  has  lono;  been  recos:- 
nized  and  practised  in  France,  and  has,  by  authors  in  that  country, 
been  accredited  to  Viardel.  Capuron  (Mai.  des  Femmes,  second 
edition,  p.  510)  describes  it,  and  Aron  and  others  give  it  special  men- 
tion. For  chronic  cases  it  is  one  of  the  best  methods  at  our  command. 
Dr.  Emmet  has  drawn  special  attention  to  it  of  late,  and  illustrated 
its  applicability  by  several  cases."  In  the  later  editions  of  the  work 
my  connection  with  the  method  is  no  longer  mentioned. 

Since  the  merits  of  the  method  are  thus  extolled  by  so  high  an 
authority,  I  hope  I  may  be  paixloned  for  attempting  to  gain  the  credit, 
certainly  due  me,  of  originality  in  its  conception.  Dr.  Thomas  is 
mistaken  in  supposing  that  the  above  plan  of  treatment,  as  described 
by  him,  was  a  familiar  one  to  Viardel.     He  has  obviously  been  mis- 


436  iNVERSiox  or  the  uterus. 

led  in  consequence  of  the  expression  used  hj  me  of  "  returning  first 
the  part  ^vhich  came  down  last."  This  principle  I  do  not  claim, 
nor  could  any  one  claim  it,  since  precisely  the  same  principle  and 
method  are  involved  in  the  reduction  of  hernia  by  taxis.  This  prin- 
ciple is  as  old  as  the  practice  of  surgery. 

In  the  report  of  my  first  case  I  gave  the  reason  which  first  led  me 
to  treat  it  on  the  principle  of  a  hernia,  and  simply  stated  the  first  step, 
as  I  might  mention  the  introduction  of  the  index  finger  into  the  vagina 
for  an  examination,  and  for  which  certainly  I  could  claim  no  origi- 
nality. While  I  treated  the  case  as  a  hernia  is  treated,  my  further 
object  was  to  shorten  the  long  axis  of  the  uterus,  and  this  was  done 
by  increasing  the  lateral  diameter  ;  that  is,  I  dilated  the  ring  about 
the  seat  of  the  inversion  by  spreading  out  my  fingers.  The  case  was 
one  of  chronic  inversion,  the  condition  for  which  the  method  is  the 
best,  if  not  solely  applicable. 

So  far  as  I  have  had  the  means  of  investio:atinc!;  the  matter,  all  the 
writers  quoted  by  Dr.  Thomas  on  this  subject  have  reference,  with- 
out exception,  to  the  treatment  of  inversion  of  the  uterus  as  it 
occurs  immediately  after  labor.  Not  one  had  any  personal  knowl- 
edore  of  the  reduction  of  a  chronic  inversion,  althouorh  several  cases 
are  mentioned  where  it  had  been  successful,  and  all  refer  to  the 
same  one  or  two  instances,  which  are  thus  simply  given  without 
being  vouched  for.  This  fact  Dr.  Thomas  thus  states,  on  page  434 
of  his  book  on  Diseases  of  Women:  "up  to  the  year  1858,  the 
reposition  of  inverted  uteri  may  be  said  to  have  been  limited  to  re- 
placement Avithin  short  periods  after  parturition.  It  is  true  that 
occasional  cases  had  occurred  in  which  chronic  inversion  had  been 
overcome  by  taxis  and  pressure,  but  these  held  the  position  of  acci- 
dental and  anomalous  feats  in  treatment,  not  that  of  systematic  pro- 
cedures, which  it  was  incumbent  upon  the  practitioner  to  essay  in 
every  case." 

In  the  first  edition  of  Yiardel's  work,  published  towards  the  close 
of  the  seventeenth  century,  no  mention  is  made  of  inversion  of  the 
uterus.  In  the  last  edition,^  published,  I  should  judge,  long  after  his 
death,  is  given,  in  all  probability,  his  whole  experience.  In  this 
only  a  single  case  of  inversion  is  mentioned,  one  in  which  he  had  de- 
livered a  woman  of  twins  ;  the  inversion  occurring  immediately  after 

•  Observations  sur  la  pratique  des  accouchemens,  etc.,  par  M.  Cosme  Viardel, 
chirurgien  a  Paris,  MDCCXLVIII. 


viardel's  "method."  437 

the  birth,  he  returned  it  without  delay.  A  chapter  is  given  "  De  la 
precipitation  ou  chute  de  la  matrice  apr^s  raccouchmcnt,  etc.,  et  de 
la  mani^re  de  la  r^duire,"  which  treats  of  procidentia  and  inversion. 
This  chapter  is  accompanied  (op.  cit.,  p.  200)  by  a  plate  to  illustrate 
the  text,  the  uterus  being  represented  outside  of  the  body,  with  the 
placenta  attached.  The  mode  of  reduction  is  then  shown  in  another 
figure,  with  a  boxwood  "  repoussoir,"  in  the  shape  of  a  drumstick, 
"for  the  womb,  to  be  used  when  the  hand  is  too  large,  and  the  neck 
too  narrow." 

After  describing  the  mode  of  returning  a  procidentia,  the  following 
is  literally  all  that  he  gives  in  relation  to  inversion  of  the  uterus: 
"  2d  method,  but  if  it  be  the  result  of  labor,  it  should  be  remedied 
after  the  manner  I  followed  in  the  case  of  the  woman  who  had  twins, 
namely,  put  a  cloth  over  the  Avhole  sm'face  of  the  womb,  and  joining 
the  jive  fingers  together  in  the  form  of  ajjensary^  it  should  he  i^iished 
up  into  its  natural  place,  making  the  patient  breathe  out,  and  having 
previously  put  her  in  a  proper  position,  namely,  the  buttocks  slightly 
elevated,  so  that  the  womb  can  the  more  readily  be  replaced,  leaving 
her  in  this  position  for  a  while,  without,  however,  constraining  her, 
and  letting  her  extend  her  legs  only,  and  hindering  her,  as  far  as 
possible,  from  talking  too  much,  from  blowing  her  nose,  and  from 
making  other  concussive  movements,  inasmuch  as  the  diaphragm 
being  pressed  downward  would  compress  all  the  contents  of  the  pelvis, 
and  in  this  way  a  second  falling  might  take  place.  To  prevent  such 
an  accident,  it  is  necessary  to  introduce  gently  a  roll  of  cloth,  which 
should  be  placed  as  far  back  as  possible,  even  to  the  internal  orifice 
of  the  womb,  not  only  to  hinder  a  refalling,  but  to  receive  the  lochia, 
leaving  a  part  outside  so  that  it  may  be  withdrawn  when  necessary." 
From  the  above  there  can  be  no  doubt  that  Viardel  referred  to  a 
recent  case  of  inversion,  and  that  the  uterus  was  reduced  in  no  other 
manner  than  by  simply  pushing  the  fundus  up  into  place. 

On  page  510  of  Capuron's  work^  is  the  following  as  referred  to  by 
Dr.  Thomas :  "  Then,  the  fingers  being  gathered  together  in  the  shape 
of  a  cone,  they  are  applied  to  the  centre  of  the  tumor  to  push  it  in 
until  the  fist  occupies  the  hollow  of  the  uterine  cavity.  But,  if  the 
orifice  be  not  sufficiently  dilated  to  allow  the  inverted  portion  to  return 
readily,  it  is  better  to  grasp  the  tumor  with  fingers  distributed  about 
the  pedicle,  and  to  begin  by  returning  that  portion  which  came  down 

'  Traite  des  maladies  des  femmes,  par  J.  Capuron,  seconde  edition,  a  Paris,  1817. 


438  INVERSIOX    OF    THE    UTERUS. 

last,  as  in  the  case  of  a  hernia."  Viardel's  name  is  not  mentioned, 
and  certainly  the  method  as  described  by  Capuron  is  not  claimed 
by  me. 

Courty,  as  the  latest  French  authority,  gives  on  page  800  of  his 
work,^  the  following  :  "But,  when  the  attempts  at  reduction  are  made 
on  a  less  recent  and  shrivelled  tumor,  of  which  the  two  peritoneal  sur- 
faces almost  touch,  it  is  hardly  possible  to  begin  the  reduction  by 
depression  of  the  fundus.  It  becomes  then  necessary  to  act  in  another 
manner,  which  seems  to  me  also  more  rational  and  applicable  to  a 
larger  number  of  cases.  It  consists  in  grasping  the  tumor  with  the 
whole  hand,  in  compressing  it,  if  it  be  swollen,  to  sijueeze  out  the 
blood  to  soften  and  relax  it,  finally  in  pressing  the  borders  by  means 
of  the  extremities  of  the  fingers  distributed  about  the  pedicle,  and 
pushing  back  that  portion  of  the  uterus  which  fonns  a  gutter,  which 
is  continuous  with  the  vaginal  portion  of  the  neck,  to  begin  by  reduc- 
ing at  the  first  that  part  nearest  to  the  orifice,  in  other  words,  the 
last  inverted,  proceeding  in  that  respect,  the  same  as  in  returning  a 
hernia." 

The  above  is  the  only  description  which  could  be  construed  into 
having  anything  in  common  with  my  method.  x\nd  yet,  the  meaning 
is  e\ident — not  to  dilate  laterally  with  any  purpose,  but  simply  to 
pass  the  finger  up  close  to  the  seat  of  inversion ;  to  treat  the  case  as 
a  hemia.  Certainly  Yiardel  is  not  mentioned  in  connection  with  it, 
nor  does  Courty  give  it  as  the  method  for  chronic  inversion,  but 
recommends  that  which  has  already  been  described  as  his  method. 

In  the  praiseworthy  desire  to  be  just,  we  are  frequently  unjust  in 
settling  a  question  of  priority.  In  my  own  case  I  have  been  unable 
to  find  anywhere  evidence  that  the  method  put  in  practice  by  me 
had  ever  been  employed  before.  Yet,  were  it  different,  I  may  still 
claim  the  credit  that  is  due  to  every  one  who,  ignorant  of  the  previous 
history,  de^dses  that  which  had  been  forgotten  and  makes  it  again 
useful. 

The  number  of  cases  must  be  exceedingly  small  where  it  would 
prove  impossible  to  restore  an  inverted  uterus  by  some  one  of  the 
different  methods  which  have  been  detailed.  But  granting  this 
possibility,  I  hold  that  the  number  is  still  smaller  where,  with  proper 
manipulation,  the  fundus  cannot  be  gotten  Avithin  the  cervix,  so  that 
it  may  be  retained  there  permanently  if  necessary. 

'  Traite  des  maladies  de  I'uterus  etc.,  Paris,  1866. 


AMPUTATION.  439 

The  advantages  of  this  latter  operation  have  been  already  presented, 
and  it  has  been  shown  that  sometimes  it  is  of  itself  sufficient  to  eftect 
the  reduction.  But  granting  that  nothing  more  can  be  accomplished 
than  a  partial  reduction  with  the  retention  of  the  fundus,  this  condi- 
tion is  certainly  preferable  to  the  danger  attending  extirpation  of  the 
uterus.  From  the  experience  gained  in  the  two  cases  under  obser- 
vation, it  is  evident  that  this  partial  restoration  is  sufficient  to  arrest 
the  hemorrhage.  It  is  also  shown  that  the  position  will  restore  the 
circulation  in  the  uterus  sufficiently  to  check  the  excessive  secretion, 
so  that  a  restoration  to  health  may  take  place  afterwards.  By  leaving 
an  opening  at  the  time  of  the  operation,  menstruation  will  continue 
unobstructed,  and  if,  by  chance,  pregnancy  should  occur,  complete 
restoration  would  no  doubt  be  brought  about. 

Dr.  Henry  Miller,  of  Louisville,  Ky.,  has  advocated^  amputation 
of  the  uterus  in  preference  not  only  to  gastrotomy  for  the  reduction, 
as  practised  by  Dr.  Thomas,  but  even  to  the  attempt  by  taxis.  He 
seems  to  claim  that  both  the  appearance  and  health  of  a  woman  are 
improved  by  removal  of  the  uterus.  He  shows  that  not  only  is  this 
so  after  the  loss  of  the  inverted  portion,  but  of  the  whole  organ,  and 
cites  a  case  where  the  uterus,  ovaries,  and  ligaments  were  all  dragged 
out  by  a  midwife,  with  the  effect  that  the  physical  condition  of  the 
woman  seemed  all  the  better  after  her  recovery.  Most  fortunate 
for  her  if  it  was  so,  but  the  ends  to  be  gained  would  hardly  justify  a 
resort  to  the  means.  Had  nature  but  realized  the  advantages  claimed 
by  the  doctor,  the  uterus  would  have  formed  no  part  of  woman's 
economy  at  the  creation. 

Dr.  Miller's  criticism  of  the  operation  I  performed  in  Mrs.  Conklin's 
case  (see  Case  XIX.),  by  shutting  up  the  fundus  within  the  cervix, 
was  that  I  "displayed  the  qualifications  of  the  ingenious  and  skilful 
operator  more  than  those  of  the  profound  pathologist."  He  asks  the 
question — "Why  should  a  uterus  rioting  in  disease  be  stored  away  in  a 
receptacle  specially  provided  for  it?  Filled  with  the  germs  of  disease, 
as  it  seemed  to  be,  is  there  not  reason  to  fear  that  these  will  multiply, 
as  in  a  hotbed,  and  bring  forth  fruit  unto  death  ?  Time  alone  can 
give  a  satisfactory  answer  to  these  questions."  There  was,  as  he 
states,  extensive  disease  of  the  utricular  glands ;  these  had  undergone 
cystic  degeneration,  a  common  condition  attending  a  change  of  life. 

•  ThoiTghts  on  Chronic  Inversion  of  the  Uterus,  etc.,  Richmond  and  Louisville 
Medical  Journal,  April,  1870. 


440  INVERSION  OF  THE  UTERUS. 

The  formation  of  these  cysts  had  resulted  in  the  destruction  of  the 
glands,  they  were  emptied  in  the  attempt  at  reduction  of  the  uterus, 
and  could  not  refill,  but  the  cavity  would  contract  and  disappear 
afterwards.  But  these  qiiestions  cannot  be  better  answered,  nor  the 
advantage  of  the  operation  better  attested,  than  by  the  fact  of  her 
restoration  to  health  and  its  continuance  for  years  after. 

It  is  possible  that  a  failure  may  occur  to  secure  a  partial  reduction, 
as  was  the  case  with  Dr.  Thomas  after  fourteen  attempts  at  taxis 
had  been  made  by  himself  and  others.  When  the  fundus  cannot 
be  secured  Avithin  the  cervix,  the  choice  will  present  itself  between 
amputation  of  the  inverted  portion,  opening  the  abdominal  wall  and 
attempting  the  reduction  from  above,  or  of  abandoning  the  case. 
Were  the  risk  of  life  to  the  patient  no  greater  than  that  from  ovari- 
otomy at  the  present  day,  I  should  favor  as  a  last  resort  the  procedure 
followed  by  Dr.  Thomas.  But  the  danger  is  greater,  since  the  perito- 
neum after  long  pressure  from  an  ovarian  tumor  would  be  in  a  very 
different  condition  and  less  liable  to  inflammation.  Yet  it  is  possible 
that,  by  the  aid  of  Lister's  method,  the  risk  of  life  may  be  lessened. 
But  with  our  present  knowledge  I  would  not  advocate  the  operation 
unless  under  such  circumstances  that  the  life  of  the  patient  was  in 
jeopardy,  and  the  choice  rested  between  it  and  amputation. 

Notwithstanding  I  have  known  three  cases  of  amputation  of  the 
uterus  in  the  practice  of  others  to  recover,  yet  I  would  not  resort  to  the 
operation  under  any  circumstances.  Dr.  West^  cites  twelve  deaths 
in  fifty  cases,  or  rather  forty-eight,  since  in  two  the  operation  was 
abandoned.  In  a  report  from  a  German  source,  in  the  American 
Journal  of  Obstetrics  for  August,  1868,  eighteen  deaths  are  stated  as 
occurring  among  fifty-eight  amputations  of  inverted  uteri.  In  one 
hundred  and  six  cases  of  amputation  by  ligature  and  otherwise,  over 
thirty-one  per  cent,  of  deaths  occurred.  Schroeder^  gives  us  the 
following :  "  adding  some  more  recent  cases  to  the  statistics  of 
Scanzoni,  we  have  the  following  results :" — • 

Total.  Recovering.                            SeaUi. 

Simple  removal         ....     14  6  (43  per  cent.)  8  (57  per  cent.) 

Simple  ligature         ....     26  19  (73  per  cent.)  7  (27  per  cent.) 

Ligature  and  removal       .         .         .     29  24  (83  per  cent.)  5  (17  per  cent.) 


'  Lectures  on  the  Diseases  of  Women,  London  edition,  p.  240. 
2  Ziemssen's  Cyclopasdia,  vol.  x.,  American  edition,  p.  221. 


AMPUTATION.  441 

Dr.  Thomas  saved  one  case  and  the  other  died,  yet  we  can  make  no 
true  estimate  of  the  actual  risk  from  so  small  a  number.  But  if  the 
mortality  from  amputation  should  prove  even  no  greater  than  that 
given  above,  the  risk  of  life  is  too  great.  Then,  apart  from  the 
danger  of  amputation,  there  is  the  additional  disadvantage  that,  if 
she  escape  with  her  life,  the  woman  is  left  mutilated  to  contend  with 
the  consequences  of  imperfect  menstruation. 

Under  ordinary  circumstances,  by  the  use  of  astringent  vaginal 
injections,  and  by  rest  at  the  time  of  the  flow,  the  tendency  to  hemor- 
rhage can  be  kept  in  check  with  almost  a  certainty  of  its  cessation 
after  a  change  of  life.  In  contrast  to  this  might  be  mentioned  the 
remarkable  degree  of  immunity  from  danger  attending  the  most  pro- 
longed attempts  at  reduction  by  taxis  and  other  means.  I  have  met 
with  but  two  instances  on  record  where  death  resulted,  and  these 
would,  doubtless,  have  been  less  likely  to  occur  at  the  present  day 
with  our  enlarged  experience. 

One  point  seems  to  be  fully  established,  viz.,  that  amputation  by 
the  ligature  alone  should  never  be  attempted,  since  the  danger  of 
peritonitis  and  blood-poisoning  is  greater  than  by  any  other  method. 
The  best  results  have  been  obtained  by  the  temporary  use  of  a  wire 
ligature,  which  is  to  be  gradually  tightened  by  twisting.  After  a  few 
days,  before  sloughing  begins,  the  body  may  be  removed  by  the 
^craseur,  scissors,  or  the  wire  cautery,  but  at  a  sufficient  distance 
from  the  ligature  to  leave  a  good  stump  in  case  of  bleeding.  The 
wire  ligature  may  then  be  carefully  loosened,  and  removed  if  there 
should  be  no  bleeding.  Another  plan  is  to  remove  the  greater 
portion  of  the  mass  by  means  of  scissors,  and  then  continue  to  tighten 
the  wire  for  a  few  days,  by  twisting  until  it  cuts  through.  In  this 
case  it  is  essential  to  guard  against  blood-poisoning,  by  applying 
strong  carbolic  acid  to  the  stump  at  the  time  of  removal.  It  is  neces- 
sary to  tighten  the  wire  loop  gradually,  since  much  pain  and  constitu- 
tional disturbance  are  likely  to  result.  This  is  explained  by  Dr. 
Barnes  to  be  due  to  compression  of  the  Fallopian  tubes,  both  of  which 
are  dragged  into  the  new  canal  formed  by  the  inversion.  The  object 
of  using  the  ligature  for  several  days  before  removing  the  mass, 
is  to  bring  about,  if  possible,  adhesion  between  the  peritoneal  surface 
lining  the  canal,  and  thus  to  close  the  opening  which  would  otherwise 
exist  into  the  peritoneal  cavity.  Another  object,  and  a  most  import- 
ant one,  is  to  cause  a  clot  to  form  and  plug  the  two  large  vessels 
running  along  the  upper  border  of  the  broad  ligaments,  from  which 


442  INVERSION    OF    THE    UTERUS. 

there  is  always  great  danger  of  fatal  hemorrhage.  It  is  always 
necessary  for  the  comfort  of  the  patient,  to  keep  her  fully  under  the 
influence  of  opium  until  the  stump  separates,  and  to  guard  against 
blood-poisoning  by  the  frequent  use  of  vaginal  injections  of  Avarm 
water,  to  which  has  been  added  brewer's  yeast,  or  a  little  carbolic 
acid. 


SUB-INVOLUTION    OF    THE    UTERUS.  443 


CHAPTER    XXII. 

SUB-INVOLUTION  OF  THE  UTERUS. 

This  condition,  together  with  its  causes,  has  been  considered  at 
some  length  under  the  head  of  general  principles.  It  was  there 
treated  of  as  a  consequence  of  faulty  nutrition,  where  from  some 
cause  the  removal  of  the  old  material,  consequent  upon  the  pregnancy, 
had  been  arrested. 

While  admitting  that  frequently  this  process  is  stopped  or  retarded 
alone  through  faulty  nutrition,  we  were  yet  inclined  to  believe  that 
in  a  far  greater  proportion  of  cases  both  the  sub-involution  and  faulty 
nutrition  were  the  effect  of  a  common  cause.  It  is  believed  that 
future  observation  will  establish  the  fact  that,  as  a  rule,  the  involution 
is  first  stayed,  and  then  faulty  nutrition  occurs  as  a  consequence  of 
some  injury  received  during  the  progress  of  labor.  To  the  occur- 
rence of  laceration  of  the  cervix,  and  to  the  formation  of  cicatricial 
tissue  in  the  vagina,  and  to  the  displacements  of  the  uterus,  by  all  of 
which  the  circulation  would  be  obstructed,  we  must,  in  most  cases, 
attribute  the  continuance  of  an  undue  size  of  the  uterus  long  after  a 
reasonable  time  has  elapsed  since  the  delivery.  Since  each  of  these 
conditions  is  specially  treated  of  under  its  appropriate  head,  their 
further  consideration  is  not  called  for  in  connection  with  sub-invo- 
lution. 

Wherever  we  find  an  instance  of  this  enlargement  of  the  uterus 
remaining  after  childbirth,  and  without  any  apparent  cause,  as  the 
reception  of  an  injury,  we  must  examine  with  the  greatest  care  into 
the  state  of  the  general  system.  When  this  is  at  fault  we  will  find 
a  want  of  tone  in  the  pelvic  venous  circulation.  Our  remedies  are 
to  be  particularly  selected  with  the  view  of  improving  the  general 
tone,  or,  in  other  words,  nutrition.  This  is  to  be  accomplished  by 
more  nutritious  food,  a  change  of  air  when  possible,  or,  if  obliged 
to  remain  at  home,  the  patient  should  be  constantly  in  the  open 
air  and  in  the  sunlight.  In  this  condition,  as  in  others  where  the 
digestion  is  feeble,  we  must  determine  what  quantity  of  food  or  of 
any  remedy  can  be  readily  taken  up  by  the  stomach  without  causing 
disturbance.     It   is,   therefore,  a  question,  not   as  to  the  quantity 


444  SUB-INVOLUTIOX    OF    THE    UTERUS. 

or  quality  which  can  be  put  into  the  stomach,  but  as  to  just  how 
much  can  be  thoroughly  digested.  AYhere  cod-liver  oil  can  be  tole- 
rated, much  benefit  may  be  expected  from  its  use.  The  continued 
use  of  small  doses  of  ergot  is  advisable  for  its  effect  on  the  coats  of 
the  vessels  ;  it  should  not  be  administered  by  the  stomach  for  fear 
of  disturbing  digestion,  but  by  the  daily  injection  of  a  sufficient 
quantity  of  the  fluid  extract  into  the  rectum.  The  hot-water  va- 
ginal injections  are  also  to  be  employed  at  least  once  a  day.  We 
will  find,  as  a  rule,  feeble  respiration  in  both  lungs,  with  an  in- 
crease of  secretion  throughout  the  air-passages,  the  condition  being 
the  one  best  fitted  for  the  rapid  development  of  tubercles.  There 
will  naturally  exist  a  certain  degree  of  prolapse  from  the  increased 
weio^ht  of  the  uterus.  This  must  entail  more  or  less  discomfort,  and 
render  the  patient  incapable  of  taking  the  requisite  amount  of  exer- 
cise. It  becomes,  then,  a  necessary  step  to  fit  a  pessary  so  that  the 
uterus  may  be  lifted  up  to  its  proper  position  in  the  pelvis,  so  that 
the  circulation  may  be  unobstructed.  When  this  is  accomplished, 
and  there  is  an  improvement  in  the  general  health,  the  old  effete 
material  will  be  gradually  removed,  and  the  uterus  will,  in  a  corre- 
sponding degree,  return  to  its  natural  size.  But  by  far  the  best  means 
for  bringing  about  this  condition  is  an  entire  change  of  scene  and  cli- 
mate. We  often  find  existing  with  the  state  of  sub-involution  follicular 
disease  of  the  throat,  and  a  more  or  less  diseased  condition  of  the 
mucous  membranes  throughout  the  body.  This  perverted  state  of  the 
mucous  membranes  is,  equally  with  sub-involution,  an  indication  of 
some  serious  defect  in  nutrition.  When  these  two  symptoms  coexist, 
the  necessity  is  the  more  urgent  for  a  temporary  change  of  air,  and 
the  selection  should  be  made  with  the  view  of  obtaining  a  dry  and 
mild  climate,  in  which  the  patient  should  pass  the  following  winter. 

In  closing  this  brief  chapter  I  would  state  that,  for  many  years  past, 
I  have  met  with  few  or  no  cases  of  sub-involution  which  were  not  due 
to  laceration  of  the  cervix. 


LACERATION  OF  THE  CERVIX  UTERI.  445 


CHAPTER    XXIII. 

LACERATION  OF  THE  CERVIX  UTERI. 

History — Etiology — Tables  XXX,  to  XXXVII.  inclusive,  being  analyses  of 
lacerations — Influence  on  menstruation. 

During  the  autumn  of  1862,  I  accidentally  recognized  the  import- 
ance of  this  lesion,  and  at  once  instituted  a  surgical  procedure  for  its 
relief.  The  operation  then  devised  has  stood  the  only  true  test,  that 
of  time,  and  has  been  but  little  modified.  From  the  above  date,  I 
have  continued  to  operate  frequently  in  both  public  and  private 
practice. 

Feb.  8, 1869, 1  described  the  operation  fully  in  a  paper^  read  before 
the  Medical  Society  of  the  County  of  New  York.  Before  the  same 
Society,  on  Sept.  28,  1874, 1  presented  an  article^  on  "  Lacerations 
of  the  Cervix  Uteri  as  a  frequent  and  unrecognized  cause  of  disease." 
This  last  paper  was  soon  after  translated  by  Br.  M.  Vogel,  and  pub- 
lished in  Berlin,  June,  1875.  Prof.  Breisky,  in  the  following  year, 
published  a  favorable  criticism^  on  the  paper  translated  by  Dr.  Vogel, 
together  with  the  report  of  fourteen  cases  successfully  treated  by  him. 

After  finding  that  some  of  the  views  presented  in  my  previous 
paper  had  not  been  fully  understood  by  the  profession,  I  read  another 
article  on  "  The  Proper  Treatment  for  Lacerations  of  the  Cervix," 
before  the  County  Medical  Society,  early  in  December,  1876,  which 
was  afterwards  published.^  This  last  article,  with  the  previous  one, 
was  soon  after  published  by  Dr.  Vogel,^  together  with  a  preface  by 
Dr.  Breisky. 

I  quote  from  Prof.  Breisky 's  paper  upon  Cicatricial  Ectropium. 

'  "Surgery  of  the  Cervix,"  American  Journal  of  Obstetrics,  Feb.  1869. 

*  American  Journal  of  Obstetrics,  Nov.  1874. 

3  Zur  Wlirdigung  des  Narbenektropiums  des  Muttermundes,  und  dessen  Ope- 
ratives Behandlung  nach  Emmet,  von  Prof.  Breisky  in  Prag.  Wiener  Med. 
Wochenschrift,  No.  49,  bis  51,  1876. 

^  American  Practitioner,  Indianapolis,  Ind.,  Jan.  1877. 

5  "  Risse  des  cervix  uteri  als  eine  haulige  und  nicht  erkannte  Krankheitsursacbe 
und  die  Behandlung  des  Risse  des  cervix  uteri.  Zwei  Schriften  von  Dr.  Thos. 
Addis  Emmet,"  etc.  Uebersetzt  von  Dr.  M.  Vogel,  mit  einem  Vorwort  von  Prof. 
Breisky  in  Prag.  Berlin,  1878. 


446  LACERATION  OF  THE  CERVIX  UTERI. 

"  German  gynsecological  literature  took  no  notice,  to  my  knowledge, 
before  the  appearance  of  the  translation  by  Dr.  ^I.  Vogel,  published 
last  year  as  a  brochure,  of  a  very  remarkable  paper  read  by  Dr.  T. 
A.  Emmet  before  the  Medical  Society  of  the  County  of  Xew  York, 
upon  Lacerations  of  the  Cer\ix  Uteri,"  etc.  "  He  describes  the 
cicatricial  ectropium  of  the  os  uteri  known  to  us  through  Eoser 
{Archiv  fur  Seilkuyide,  II  Jahrgang  Heft,  Leipzig,  0.  Wigand,  76, 
No.  298),  and  for  the  first  time  established  its  pathological  signifi- 
cance as  well  as  its  treatment.  That  to  Emmet,  in  fact,  belongs  this 
essential  share  in  the  question,  follows  indubitably  from  a  considera- 
tion of  Roser's  treatise.  "While  Roser,  in  describing  his  two  forms  of 
ectropium,  one  of  which  originates  through  cicatricial  distortion,  the 
other  by  the  crowding  forward  and  swelling  of  the  mucous  membrane, 
chiefly  concerned  himself  with  the  latter  form,  and  with  the  correction 
of  Lisfranc's  interpretation  of  this  condition  as  "  granulation"  of  the 
mouth  of  the  womb,  he  devotes  only  a  few  words  to  the  cicatricial 
ectropium,  which  he  does  not  regard  as  frequent.  Roser  indicates  as 
its  cause  excessive  fissures,  also  probably  obstetrical  incisions  and 
gangrenous  destruction  of  the  mouth  of  the  womb."  "  Roser  discusses 
the  inflammatory  ectropium  described  by  him  in  detail,  also  with  regard 
to  its  therapeutics,  in  a  searching  manner,  and  observes,  among  other 
things,  ^Jlani/  cases  of  ohstinate  and  inveterate  Tiypertropliy  of  the 
lowest  part  of  the  uterine  mucous  membrane  ma.y  he  considered  as 
incurable,  since  retrograde  metamorphosis,  shrinking,  and  atrophy  do 
not  take  place,  and  an  entire  excision  of  this  part,  from  the  slight 
significance  of  the  lesion  (in  many  cases  to  be  regarded  as  almost 
nothing)  is  not  to  be  recommended.'  Roser  manifestly  did  not  give 
any  higher  significance  to  the  cicatricial  ectropium,  for  he  says  'm 
the  cicatricial  ectropium  of  the  uterine  mucous  membrane,  one  will 
scarcely  be  jJrompted  to  undertake  a  curative  experiment.'  This  is  all 
that  was  known  upon  the  subject  before  Emmet's  treatise."  "Accord- 
ingly, we  undoubtedly  owe  to  Roser  the  first  anatomical  and  etio- 
logical exposition  of  cicatricial  ectropium  ;  to  Emmet,  however,  on 
the  other  hand,  remains  the  priority  of  having  appreciated  and  taught 
a  knowledge  of  the  clinical  significance  and  the  successful  surgical 
treatment  of  this  affection." 

From  Rosen's  description  it  seems  evident  that  he  only  referred  to 
the  condition  where  a  fissure  is  left  after  a  laceration  of  the  cervix. 
This  result  every  one  would  easily  recognize,  but  until  recently  no 
one  attached  any  more  importance  to  the  lesion  than  he  did.  But  by 
far  the  most  frequent,  as  well  as  the  most  important  condition,  and 


ETIOLOGY.  447 

the  one  easiest  relieved,  he  certainly  did  not  appreciate.  After  the 
parts  have  been  torn  and  -while  they  are  soft  enough  to  be  flattened 
out  by  pressure  on  the  floor  of  the  pelvis,  there  remains  no  evidence 
of  the  laceration,  and  the  true  condition  frequently  cannot  be  detected 
by  either  the  sight  or  by  the  sense  of  touch.  Roser  had  not  even  an 
appreciation  of  the  causes  at  work  in  producing  the  condition  he  has 
described.  This  is  evident  from  his  use  of  the  term  "  cicatricial 
ectropiura,"  since  the  formation  of  cicatricial  tissue  is  only  an  inci- 
dent. Prof.  Breisky,  in  his  preface  to  Dr.  Vogel's  translation,  quotes 
from  my  letter  to  him :  "  I  must  take  exception  to  the  term  '  cica- 
tricial ectropium'  as  not  being  the  true  pathology.  There  can  be  no 
cicatricial  tissue  formed  except  on  the  surfaces  lacerated,  and  if  this 
tissue  contracts,  it  would  have  the  efiect  of  rolling  in  the  parts  instead 
of  what  does  occur.  When  the  condition  is  produced  on  the  lower 
eyelid,  the  mucous  membrane  is  not  exposed  from  cicatricial  tissue  on 
this  surface,  but  from  the  cicatricial  tissue  on  the  skin  outside  causing 
the  traction.  The  flaps  in  the  cervix  are  first  rolled  out,  or  forced 
apart  from  the  large  uterus  resting  on  the  floor  of  the  pelvis,  and  this 
is  increased  as  the  circulation  becomes  obstructed,  and  as  the  mucous 
follicles  undergo  cystic  degeneration.  The  condition  at  length  be- 
comes one  of  partial  strangulation,  as  in  paraphimosis.  When  nature 
attempts  to  fill  up  the  angle  by  cicatricial  tissue,  the  parts  are  pre- 
vented from  rolling  out,  and  we  then  have  the  fissure  left." 

Etiology  of  Lacerations  of  the  Cervix  Uteri. — Previous  to  collect- 
ing the  statistical  material  for  this  work,  I  had  recognized  and  treated 
two  hundred  and  nineteen  cases  of  lacerations  of  the  cervix  in  ray 
private  hospital.  This  shows  that  a  little  over  sixteen  per  cent,  of 
all  women  Avho  had  passed  under  my  observation,  and  had  been  im- 
pregnated, were  found  to  have  had  laceration  of  the  cervix.  This 
proportion  will  seem  to  many  a  large  one,  and  yet,  as  the  record 
extends  over  thirteen  years,  doubtless,  many  cases  during  that  period 
were  not  recognized.  It  was  fully  six  years  after  my  first  operation 
before  I  had  gained  experience  enough  to  detect  this  lesion  under  its 
varied  forms,  while  the  treatment  itself  was  not  perfected  until  several 
years  later. 

To  arrive  at  more  definite  results  as  to  the  frequency  of  this 
injury,  I  have  taken  from  my  case  books  the  records  of  the  last  five 
hundred  fruitful  women  coming  under  my  care  in  private  practice. 
The  result  is  reached  that  32.80  per  cent,  of  all  women  under  observa- 
tion, who  had  been  impregnated,  and  had  suffered  from  some  form  of 
uterine  disease,  were  found  to  have  laceration  of  the  cervix.     It  is,  of 


4i8 


LACERATIOX  OF  THE  CERVIX  UTERI. 


% 


e 
S 
% 


UOpJOqB 

Xi!uiniu3 


•saSBiuBasijc 


•AnioioraBJO 


•SniiLnix 


•sdaaioj;  o       -^       o 


•snorpax 


Jr-  r-i  Tf 


■pidEH 


•IBJnjBx     I      cq       (M       Ci       5-1       C-1       ^ 


CQ 


•notsaj  TjD^a 
10}  jaqmnu  ieiox 


X 
H 


•aSBUj^K 


•Zjjaqnj 


• 

• 

• 

^^ 

© 

o 

,a 

o 

'tc 

a 

3 

S         aj 

^ 

a 

n        -^ 

■«^ 

p^ 

^      To 

^ 

^ 

-« 

O 

3           O 

iC 

■: 

ci 

H 

J         -^ 

^ 

"T" 

;j 

,^ 

-        r~ 

^^ 

-■ 

::.) 

^ 

ANALYSIS    OF    LACERATION.  449 

course,  possible  that  this  increase  in  the  percentage  is  due  in  a  measure, 
but  not  wholly,  to  the  fact  that  cases  were  sent  to  me  by  general 
practitioners  ;  but  in  few  instances  had  there  been  a  diagnosis  made. 
The  average  age  at  puberty  for  women  who  had  lacerations  was, 
as  will  be  seen  by  Table  XXXIII.,  14  years,  and  at  marriage  21.47 
years.  These  averages  approximate  so  closely  to  those  of  all  women 
under  observation,  that  it  is  evident  neither  the  time  of  puberty  nor  of 
marriage  had  any  bearing  on  the  cause  of  the  lesion.  These  women 
first  came  under  my  observation  at  about  the  average  age  of  thirty- 
three  years  and  four  months,  the  greatest  deviation  being  for  those 
who  had  suffered  from  backward  laceration.  While  the  number  of 
cases  is  too  small  to  give  any  importance  to  the  circumstance,  it  is 
not  entirely  an  accidental  one,  since  it  is  a  form  of  laceration  which 
would  produce  the  least  disturbance,  and  then  only  later  in  life  as  the 
vagina  becomes  changed  in  shape.  In  one  of  the  columns  of  the  table 
wall  be  found  the  number  of  the  different  forms  of  laceration,  and 
their  i-elative  frequency.  It  will  be  seen  that  the  injury  on  the  left 
side  is  the  most  common,  and  double  laceration  the  next.  To  establish 
with  some  degree  of  accuracy  the  character  of  the  labor  most  likely 
to  result  in  laceration  of  the  cervix,  would  be  an  important  advance. 
I  endeavored  with  great  care  to  ascertain  from  each  of  these  women 
the  prominent  features  of  the  labor  in  which  it  was  supposed  the 
accident  occurred.  Notwithstanding  I  had  so  intelligent  a  class  to 
deal  with,  I  feel  that  the  information  gained  is  to  be  accepted  only  as 
approximating  to  the  truth.  The  testimony  of  a  patient  as  to  her 
labors,  and  particularly  the  first  one,  to  be  of  value,  must  be  confirmed 
by  careful  observation  on  the  part  of  the  attending  physician.  From 
a  priori  inference  I  had  been  prepared  to  learn  that  rapid  labor  was 
the  most  common  cause  of  laceration  of  the  cervix.  The  contrary, 
however,  has  proved  to  be  the  case,  as  more  than  thirty  per  cent,  of 
the  lacerations  were  attributed  to  tedious  labor.  This  proportion 
would  be  greatly  increased  by  the  addition  of  the  forceps  cases,  which 
properly  should  be  placed  under  the  head  of  tedious  labor,  since,  we 
may  assume,  forceps  were  only  employed  for  delivery  after  the  labor 
had  been  prolonged.  It  will  be  noted  that  two  instances  of  laceration 
occurred  from  miscarriage,  and  ten  as  a  consequence  of  criminal 
abortion.  Since  my  attention  has  been  directed  to  this  subject,  I 
have  found  the  cervix  lacerated  in  every  instance  where  the  patient 
admitted  the  fact  of  exposure  to  malpractice.  And  my  suspicions 
have  been  verified  several  times  by  the  patient  acknowledging  the 
charge  which  I  felt  justified  in  making  whenever  I  detected  a  lacera- 
29 


450  LACERATION  OF  THE  CERVIX  UTERI. 

tion  produced  by  discharge  of  the  uterine  contents  before  full  term. 
It  can  readily  be  understood  that  laceration  of  the  cervix  would  occur 
under  these  circumstances  as  well  as  in  rapid  labor  where  the  parts 
are  so  quickly  dilated  ;  but  as  the  result  of  a  tedious  labor,  it  is  not 
so  clear,  since  sloughing  would  then  be  a  more  likely  consequence. 
If  the  delay  was  in  the  first  stage  of  labor_,  with  the  os  tardy  in 
dilating,  a  condition  of  the  soft  parts  might  be  established  which 
would  readily  admit  of  the  occurrence  of  this  accident.  But,  as  a 
rule,  the  effect  of  a  tedious  labor  would  scarcely  be  asserted  until 
long  after  full  dilatation  of  the  cervix  had  been  accomplished.  I 
cannot  divest  myself  of  the  conviction  that  rapid  labor  will  be 
found,  on  further  observation,  to  be  a  far  more  important  factor  in 
causing  this  lesion  than  has  been  indicated  by  this  record.  The  pro- 
portion of  rapid  labors,  as  given,  is  much  more  likely  to  be  correct 
than  the  contrary.  For  it  is  a  very  natural  error  for  a  woman  to  ex- 
aggerate the  time,  and  to  regard  a  labor  as  tedious,  although  it  may 
have  been  a  natural  one  in  every  respect. 

Observation  must  determine  what  part  meddlesome  midwifery  plays 
in  producing  this  accident.  The  practice  of  rubbing  the  finger  around 
the  OS  to  excite  contraction,  and  of  stripping  back  the  cervix  from  the 
head,  with  the  view  of  facilitating  the  progress  of  labor,  may  be 
pernicious  ;  but  the  consequences  of  any  such  interference  must  be 
very  limited,  since  the  history  of  many  well-marked  cases  shows  that 
labor  was  terminated  before  the  arrival  of  the  physician. 

This  lesion  is  found  as  frequently  among  the  well-to-do,  who  have 
every  advantage  of  competent  medical  attendance,  as  among  the  poor. 
Of  those  from  whom  the  material  Ave  have  been  considering  was 
obtained,  all  were  treated  in  my  private  practice.  They  were  from 
all  parts  of  the  United  States,  and  were,  without  exception,  able  to 
command  the  best  professional  skill  in  their  neighborhood.  I  have 
employed  every  means  at  my  command  to  settle  this  point,  and  my 
conclusion  is  to  the  effect  that  in  no  one  station  of  life  is  the  woman 
more  liable  to  this  accident  than  in  another,  provided  the  cases  of 
instrumental  delivery  are  excluded.  When  laceration  does  occur 
from  delivery  by  forceps,  among  the  poorer  classes,  it  is  almost  always 
double,  and  I  have  seen,  at  the  Woman's  Hospital,  an  extent  of  injury 
never  met  with  in  private  practice.  Upon  consulting  the  records  of 
i/he  physicians  attending  these  cases,  it  is  evident  that  there  are  some 
who,  with  a  view  to  saving  time,  are  in  the  habit  on  their  arrival  of 
delivering  by  forceps,  without  apparently  the  slightest  reference  to  the 
staiie"  of  labor.     There  can  be  no  doubt  of  the  fact  that  among  the 


ANALYSIS    OF    TABLES.  451 

poor,  in  this  city  at  least,  the  forceps  are  employed  to  a  greater 
extent  than  would  be  permitted  among  the  wealthier  classes.  As  the 
more  frequent  victims  of  this  mode  of  practice,  lacerations  of  the  cervix 
should  be  more  commonly  met  with  among  the  poor  of  the  large  cities, 
but  the  proportion  is  not  greater  than  for  those  from  the  smaller  towns 
or  country. 

We  will  now  complete  the  consideration  of  Table  XXXIII.  by 
reference  to  the  last  column,  in  which  is  recorded  the  average  dura- 
tion, or  the  interval,  since  the  last  pregnancy.  The  average  length  of 
time  in  all  forms  of  laceration  was  found  to  be  rather  more  than  five 
years.  The  relative  duration  of  this  interval,  with  respect  to  any 
one  special  form  of  laceration,  is  not  sufficiently  marked  for  comment, 
with  the  single  exception  of  the  backward  lacerations.  In  this 
form  the  state  of  quasi  sterility  had  existed  for  twice  the  length 
of  time  given  for  any  other  form  of  the  injury.  The  proportion  of 
these  cases,  as  we  have  already  noted,  is  smaller  than  any  other,  but 
the  sterility  was  naturally  produced  by  the  greater  or  less  degree  of 
retroversion,  which  existed  as  a  result  of  the  laceration  extending  into 
the  posterior  cul-de-sac,  and  causing  contraction  of  the  parts  or  tissues 
located  posteriorly. 

Table  XXXIY.  exhibits  the  number  of  impregnations  taking  place 
previous  to  the  reception  of  the  injury.  One  hundred  and  thirty-eight 
women  bore  407  children,  and  never  miscarried.  Eighteen  had  79 
children,  and  84  miscarriages.  Five  had  miscarriages  alone,  and 
three  had  criminal  abortions  produced,  which  caused  laceration  of  the 
cervix.  One  hundred  and  sixty-four  women  were  impregnated  528 
times  before  the  occurrence  of  laceration,  which  gives  an  average  of 
3.21  impregnations  for  each  woman.  The  next  division  of  the  table 
is  formed  from  the  statement  of  the  patients  as  to  the  number  of 
impregnations  they  supj^osed  had  taken  place  after  the  occurrence  of 
the  injury.  This  is  only  valuable  in  showing  that  71.34  per  cent, 
at  least  remained  sterile,  while  there  is  no  proof  that  a  single  case 
became  impregnated  after  the  occurrence  of  the  laceration.  The  last 
portion  of  the  table  gives  the  total  number  of  impregnations,  and 
shows  that  164  women  were  delivered  of  514  children,  and  had  84 
miscarriages  ;  and  5  women  had  been  subjected  to  10  criminal  abor- 
tions. This  would  furnish  an  average  of  3.18  children  for  each 
woman,  which  is  almost  identically  the  same  as  the  average  number  of 
children  borne  by  all  the  women  under  observation.  If  the  number 
of  children  and  miscarriages,  that  is,  if  the  whole  number  of  im- 
pregnations be  taken,  the  average  would  be  3.70  for  each  woman,  a 


452 


LACERATION  OF  THE  CERVIX  UTERI. 


proportion  greater  than  that  for  all  women  passing  under  my  observa- 
tion, without  reference  to  this  lesion. 


Table  XXXIV Showing  the  number  of  Impregnations  previous  and 

subsequent  to  the  reception  of  the  Injury. 


o     . 

la 

C    o 

9 

5 

!50 

.2 

U 

to 

.2  "3 

—.  a 

0 .2 

^  p. 

Impregnations   "before   the   injury, 
i-esulting  in — 

Children  alone 

Both  cliildren  and  miscarriages 

Miscarriages  alone 

Criminal  abortions 

138 

18 

5 

3 

407 
79 

"34* 

5 

"3' 

407 

113 

5 

3 

Number  of  women  and  preg-  ) 
nancies  before  injury  .     .   ) 

1G4 

.... 

.... 

528 

Impregnations    after    the    injury, 
resulting  in,  as  supposed — 

Children  alone 

Both  children  and  miscarriages 

Miscarriages  alone 

Criminal  abortions       .... 

17 
4 

24 
2 

20 

8 

"s* 

"37' 

""7' 

37 

20 

61 

9 

Number  of  women  and  preg-  ) 
nancies  after  injury      .     .   ) 

47 

.... 

80 

Summary — 

Cliildren  alone 

Both  children  and  miscarriages 

Miscarriages  alone 

Criminal  abortions       .... 

427 
87 

"42' 

42' 

"16" 

427 

129 

42 

10 

1 

Total  number  of  women  and  ) 
impregnations      .     .     .     .   j 

164 

514 

42 

42 

10 

608 

Menstrual  Changes. — The  average  duration  at  puberty  of  the 
menstrual  flow  for  the  164  women  who  suffered  from  laceration  of  the 
cervix  was  4.78  days,  while  that  on  the  general  average  for  2080 
women  was  4.82  days.  These  averages  are  essentially  the  same, 
and,  as  there  was  no  marked  difference  in  the  early  history  of  men- 
struation, cither  as  to  the  degree  of  pain  or  regularity,  it  is  evident 
the  condition  at  puberty  would  furnish  no  indication  of  subsequent 
liability  to  this  lesion. 


SEAT    OF    LACERATION,   ETC. 


453 


o  _  5 


•(sjCiip)  pouad 
JO  miJiui  -AV 


•-•        t        'i        <-• 

■^      ■^      00      -r 


»  2  »  =  2  >• 
fc.  3  ^  ^.5  !5 


•(sXup)  pouad 
JO  mfluai  -AV 


■sasna  JO  -o^j 


t-  a  -<! 


•(Sji-Bp)  iiouad 
JO  mSnaj  -Ay 


•sasBo  JO  'OH 


■(s^^Bp)  pouad 
JO  mguaj  -AV 


•sas'Bo  JO  'Oil 


•(SiiBp)  poi.iad 
JO  q}3u9i  -Ay 


•sasBD  JO  'o^i 


6.  <•  f- 

c  2  ^ 

t5  a  z 

3  «  o 


*-  t^  o  3  c  ^ 

S  5  ~  ^   O   to 

a  r  a     .J:  u 

CO  C;    -;   =i        ,2 


•(Sjiup)  pouad 
JO  m^naf  -AV 


•sas'EO  JO  'o^ 


•(s^'Bp)  pouad 
JO  ^'^Sa^i  -AV 


•sasBO  JO  'oji 


•(s^Bp)  pouad 
JO  q^Suai  "Ay 


■sas'Ba  JO  "o  VI 


•(siT!p)  pouad 
JO  q^Suai  -Ay 


■sas-BO  JO  -0^ 


5  -?  >5  s 


r  => 

sr 

" 

. 

•d 

iJ 

o 

rs 

<s 

a 

L 

5 

•(s^X^p)  pouad 
JO  mana["  -Ay 


•sas'Bo  JO  'ojj 


•(s^fiip)  pouad 
JO  T^Suai  'Ay 


•sas-BO  JO  'O^ 


•(s^-Ep)  poi.iad 
JO  mgnaj  -Ay 


•sasBa  JO  '0)1 


e-  2  z 

£-S 

a 

? 

» 

cj  <=;  g 

K  =  -  3 

^£5" 

•(sX'Bp)  poudd 
JO  n}3uai  'Ay 


•sasBO  JO  "o^i 

•(siCTip)  pouad 
JO  m^uai  'Ay 


•sasBO  JO  -on 


•(sXvp)  pouad 
JO  qiiiuax  'Ay 


•sasBa  JO  'o)! 


oc 

!0 

o 
■* 

to 

<M 

to 

CO 

CO 

^ 

t^ 

o 
o 

CO 

CO 

o 
o 

■:0 

rH 

o. 

(M 

=o 

r- 

454 


LACERATION  OF  THE  CERVIX  UTERI, 


It  will,  however,  be  of  importance  to  study  the  subsequent  changes 
in  menstruation,  as  brought  about  by  laceration  of  the  cervix. 

Table  XXXV.  shows  the  subsequent  changes  in  duration  of  the 
menstrual  flow  in  219  cases  of  laceration  of  the  cervix.  We  there  see 
that  but  17.80  per  cent,  of  this  number  continued  after  the  injury  with- 
out change  in  the  menstrual  flow  from  what  it  was  after  puberty.  This 
proportion  was  obtained  from  those  who  remained  in  after  life  normal, 
too  free,  or  scanty  in  the  flow,  but  in  whom  there  had  been  no  change 
in  consequence  of  the  injury.  The  same  table,  however,  shows  that 
with  only  12.33  per  cent,  was  the  menstrual  flow  normal  in  after  life. 

Table  XXXVI.  shows  that  130  women,  or  79.26  per  cent,  of  the 
164  cases  with  laceration,  had  the  flow  increased  or  lessened  in  dura- 
tion or  amount  in  consequence  of  the  injury.  Eighty-two  women  had 
the  flow  increased  from  4.68  days,  as  it  was  at  puberty,  to  7.07  days 
in  after  life.  This  number  is  there  shown  to  be  63.07  per  cent,  of 
130  cases  with  whom  a  change  took  place,  or  50  per  cent,  of  the 
total  number  with  laceration,  who  had  the  flow  increased  in  quantity. 
I  can  offer  no  explanation  for  the  circumstance  where  we  find  the 
average  length  of  the  menstruation  at  puberty  is  so  much  greater  for 
the  forty-eight  women,  with  whom  the  flow  became  lessened  in  after 
life,  than  for  those  who  had  it  increased.  It  would  have  been  natural 
to  anticipate  the  opposite  effect. 


Table  XXXVI. — Epitome  of  Changes  in  the  Duration  of  the  Menstrual 
Flow  in  130  cases  of  Laceration  of  the  Cervix. 


^'uml)er  of 
ca  ics  with 

the  flow 

iacreased 

or 

lesscued. 

Changes  in  duration  of 
menstrual  flow. 

In  days. 

Percentage 

From 

To 

On  the 
changes. 

On  the 
total  number. 

As  to 
puberty 

In 
after-life. 

82 
48 

Increased    .     .     . 
Lessened     .     .     . 

4.68 
5.16 

7.07 
3.56 

63.07 
36.92 

50.00 
29.26 

130 

Changed      .     .     . 

4.86 

5.70 

.... 

79.26 

We  find  at  puberty  the  average  length  of  the  menstrual  flow  for 
these  130  women  was  4.86  days.  On  taking  the  average  for  these 
women  in  after  life,  without  regard  to  any  change  taking  place  in 
the  increase  or  lessening  of  the  flow,  it  will  be  found  to  be  5.70  days, 


INFLUENCE    ON    MENSTRUATION.  455 

thus  showing  that  the  general  effect  of  the  injury  is  to  increase  in 
after  life  the  length  of  the  menstrual  flow  by  an  average  of  nearly 
one  day. 

Table  XXXV.  may  be  considered  in  two  portions.  The  first  in- 
cludes 137  women  Avith  whom  the  length  of  menstruation  remained 
unchanged,  or  62.55  per  cent,  of  the  total  number.  These  are  again 
subdivided :  the  first  subsection  is  made  up  of  39  women  in  whom  the 
flow,  after  the  accident,  remained  unchanged  as  to  time  and  quantity, 
or  17.80  per  cent,  of  the  total  number.  The  second  subsection  con- 
sists of  98  women,  constituting  44.74  per  cent,  of  the  whole  number 
of  lacerations.  With  these  the  length  of  flow  remained  unchanged, 
but  the  quantity  increased,  lessened,  or  became  irregular.  It  may, 
therefore,  be  stated,  that  of  the  137  women  with  whom  the  time  re- 
mained unchanged,  28.46  per  cent,  continued  to  be  normal,  too  free, 
or  scanty,  as  they  had  been  from  puberty,  while  71.53  per  cent,  had 
the  quantity  altered. 

The  second  section  is  formed  of  82  women  who  constituted  37.44 
per  cent,  of  the  total  number;  with  these  both  time  and  quantity 
had  undergone  a  change  after  laceration  of  the  cervix.  Two  sub- 
divisions are  also  made  here  :  in  26.48  per  cent,  the  length  of  period 
became  increased,  and  in  10.95  per  cent,  lessened.  Again,  of  those 
with  whom  the  time  became  changed,  it  was  lengthened  with  70.73 
per  cent.,  and  lessened  in  29.26  per  cent,  without  reference  to  changes 
in  quantity.  The  number  of  menstrual  days  is  given  for  each  con- 
dition, but  in  this  respect  the  information  is  of  limited  value  except 
for  lacerations  as  a  class,  since  for  so  large  a  proportion  the  locality 
of  the  injury  had  not  been  noted. 

In  conclusion  of  this  subject  a  brief  study  of  Table  XXXVII.  will 
prove  of  interest.  Here  we  have  the  condition  as  to  quantity  treated 
of  without  reference  to  the  length  of  the  menstrual  flow,  the  average 
duration  for  each  condition  being  given  merely  as  a  coincidence. 
To  reach  the  results  for  each  condition  shown  by  this  table,  we  found 
first  the  number  of  cases,  then  the  total  number  of  menstrual  days, 
afterwards  the  average  duration  of  flow,  and  finally  the  proportions. 
But  on  making  a  comparison  with  Table  XXXVI.  it  must  be  borne  in 
mind  that  the  two  tables  not  only  treat  of  difierent  sets  of  cases,  but  that 
one  records  the  eff"ect  of  the  injury  on  the  length  of  menstruation,  while 
the  other  treats  of  the  quantity.  For  example  :  a  woman  may  have 
had  the  length  of  the  menstrual  flow  doubled,  and  yet  the  aggregate 
quantity  may  have  been  lessened.  Again,  the  converge  may  be  true, 
the  duration  of  flow  being  shortened,  and  the  quantity  increased.    With 


456 


LACERATION  OF  THE  CERVIX  UTERI. 


this  explanation  any  apparent  discrepancy  will  be  understood.  One  fact 
is  made  prominent  by  comparison  between  these  two  tables,  viz.,  that 
the  causes  of  a  lengthening  of  the  time  of  the  menstrual  flow  and 
an  increase  in  quantity,  are  almost  identical.  The  connection  be- 
tween a  shortening  of  the  time  and  a  diminution  in  quantity,  is  almost 
as  well  marked,  but  the  other  conditions,  in  their  relation  to  time  and 
quantity,  do  not  seem  governed  by  any  obvious  law. 

Table  XXXVII Epitome  of  Condition  as  to  the  Quantity  of  the 

Menstrual  Flow  in  219  cases  of  Laceration  of  the  Cervix. 


Condition  of  Menstraation. 

Number  of 
cases. 

Total  num- 
ber of 

menstrual 
days. 

Average 

length  of 

period. 

Average 

for  each 

condition. 

Remaining  as  before  the  injury, 
being 

Normal 

Too  free 

Scanty 

27 
4 

8 

120 
32 
23 

4.44 
8.00 

2.87 

12.32 
1.83 
3.65 

Changing     after     the     injury, 
being 

Increased  

Lessened 

Irregular 

113 

43 
21 

734 
179 
115 

6.49 
3.84 
5.47 

51.59 

21.00 

9.58 

Total 

219 

1203 

5.49 

Differences  in  quantity  are,  as  a  rule,  to  be  attributed  to  the  date 
of  the  accident,  and  conditions  of  the  surfaces  afterwards.  Whenever 
the  laceration  has  been  somewhat  recent,  the  flow  will  be  the  more 
profuse  or  irregular.  But  if  the  injury  has  been  one  of  long  standing, 
so  that  the  mucous  membrane  has  undergone  extensive  cystic  degene- 
ration, and  atrophy  has  already  begun,  the  flow  will  become  less  in 
quantity,  and  also  irregular.  That  the  menstrual  flow  should  remain 
unchanged  in  a  certain  proportion  of  cases,  can  only  be  explained  on 
the  ground  of  a  difference  in  the  extent  of  injury. 

The  occurrence  of  cellulitis  in  connection  with,  or  as  a  consequence 
of,  laceration  of  the  cervix  is  the  most  important  as  it  is  the  most 
frequent  complication.  Although  a  large  number  of  cases  of  cellu- 
litis were  recorded  in  connection  with  those  forming  Table  II.,  I  will, 
for  the  reasons  already  given,  confine  myself  to  the  material  furnished 
from  the  histories  of  the  164  women  which  were  the  last  under  ob- 
servation. 


INFLUENCE  ON  MENSTRUATION.  457 

Of  these  33,  or  20.12  per  cent,  of  the  total  number,  had  cellulitis 
at  the  time  of  their  first  examination.  It  would,  of  course,  be  impos- 
sible to  estimate  what  the  proportion  was  of  those  who  had  recovered 
from  an  attack  of  cellulitis  in  the  interval,  since  an  average  of  over 
five  years  had  elapsed  between  the  birth  of  the  last  child  and  my 
first  examination. 

Eleven  Avomen,  or  33.33  per  cent,  of  all  having  cellulitis  when 
first  seen,  had  the  menstrual  flow  increased;  16,  or  48.48  per  cent., 
had  it  lessened ;  while  6  women,  or  18.17  per  cent.,  suffered  no 
change  after  the  reception  of  the  injury.  Where  the  duration  of  the 
flow  had  been  lengthened,  the  average  increase  was  from  4.36  days, 
at  puberty,  to  6.63  days  after  the  injury,  while  with  a  larger  number 
the  period  was  lessened  from  5.50  days  to  4.12  days.  The  average 
leno;tli  of  menstruation  for  the  total  number  of  those  women  who  had 
cellulitis  was  5.03  days  at  puberty,  and  but  5.14  days  in  after  life, 
if  the  average  be  taken  without  regard  to  changes. 

The  unexplained  circumstance  already  referred  to  is  here  again 
noted,  that  those  women  who  had  the  menstrual  flow  lessened  in  after 
life  began  at  puberty  with  the  period  of  longer  average  duration  than 
was  the  case  with  those  where  it  became  increased  after  the  occur- 
rence of  the  laceration.  Future  observation  must  determine  how  far 
the  complication  of  cellulitis  with  lacerations  of  the  cervix  may  lessen 
the  average  duration  of  menstruation,  for  it  would  be  natural  to  sup- 
pose that  this  injury  would  tend  rather  to  increase  the  flow.  Its  in- 
direct effect  also  on  the  circulation,  in  bringing  about  early  atrophy 
by  a  certain  degree  of  obstruction,  has  yet  to  be  studied.  Experience 
has  fully  demonstrated  the  importance  of  recognizing  its  existence  in 
connection  with  the  proper  treatment  of  lacerations  of  the  cervix,  and 
the  subject  will  be  treated  of  at  greater  length  under  the  proper  head. 


458  DIAGNOSIS    AND    TREATMENT    OF 


CHAPTER   XXIV. 

DIAGNOSIS  AND  TREATMENT  OF  LACERATIONS  OF  THE  CERVIX 

UTERI. 

Diag7iosis. — Lacerations  through  the  neck  of  the  uterus  are  of 
more  frequent  occurrence  than  has  been  supposed.  In  fact,  I  doubt  if 
a  -woman  can  give  birth  to  her  first  child  without  partial  laceration 
taking  place  ;  but  if  it  is  slight  it  heals  rapidly  and  causes  no  difficulty 
afterwards.  Even  most  extensive  tears  are  seldom  recognized  at  the 
time  of  labor.  The  tissues  are  then  so  soft  that,  unless  the  rent  has 
passed  beyond  the  cervix  into  the  vagina  and  connective  tissues,  it 
can  scarcely  be  detected  by  a  mere  digital  examination.  Indeed,  the 
occurrence  of  the  accident,  in  all  probability,  will  not  even  be  sus- 
pected, unless  an  unusual  amount  of  hemorrhage  should  exist. 

Lacerations  in  the  median  line  are  the  most  frequent,  and  those 
through  the  anterior  lip  are  more  common  than  those  in  the  posterior 
one.  When  in  the  median  line  and  confined  to  the  cervix,  these 
lacerations  generally  heal  rapidly,  leaving  scarcely  a  cicatricial  line 
to  mark  their  course.  This  is  due  to  the  fact  that  the  necessary 
recumbent  position  of  the  patient,  which  is  enforced  for  some  time 
after  labor,  keeps  the  raw  surfaces  in  close  contact  by  the  pressure  of 
the  lateral  Avails  of  the  vagina  until  they  have  become  firmly  united. 

No  serious  consequences,  therefore,  are  likely  to  follow  this  acci- 
dent through  the  anterior  lip  of  the  uterus,  unless  the  rent  passes 
beyond  the  cer\ax  through  the  septum  into  the  bladder.  Even  when 
most  extensive,  the  line  may  heal  throughout,  as  there  will  have  been 
no  loss  of  tissue  from  sloughing.  This  will  frequently  be  the  result 
if  proper  attention  has  been  paid  to  cleanliness,  by  the  use  of  vaginal 
injections  of  warm  water,  so  as  to  prevent  phosphatic  deposits  from 
the  urine  on  the  raw  surfaces. 

But,  as  a  rule,  when  the  tear  has  been  so  extensive,  a  small  vesico- 
vaginal fistula  will  be  left  in  front  of  the  cervix.  Or  the  laceration 
through  the  neck  will  heal  from  above  downward,  and  leave  at  the 
bottom  of  the  fissure  a  sinus,  along  which  the  urine  will  escape  from 
the  bladder  into  the  uterine  canal.     Under  the  proper  head  this  form 


LACEllATIONS    OF    THE    CERVIX    UTERI.  459 

of  fistula  Avill  be  treated  of  at  length.  Lacerations  through  the  ante- 
rior lip  generally  occur  in  women  who  have  borne  a  number  of  child- 
ren, and  in  whom  there  exists  great  relaxation  of  the  abdominal  walls, 
and  anterior  obliquity  of  the  uterus. 

Lacerations  through  the  posterior  lip  unite  as  readily,  and  the 
accident  may  not  be  suspected,  unless  the  fissure  should  have  ex- 
tended sufficiently  into  the  posterior  cul-de-sac  to  set  up  an  attack  of 
inflammation.  When  cellulitis  occurs  at  this  point,  and  from  this 
cause,  it  always  induces  a  most  intractable  form  of  retroversion. 
Even  when  a  laceration  has  been  superficial  on  the  vaginal  surface, 
the  cicatricial  band,  felt  as  a  cord,  will  contract  and  so  shorten  the 
cul-de-sac  as  to  render  it  impossible  to  adapt  any  form  of  pessary 
to  it.  To  restore  the  uterus  to  its  natural  position,  a  surgical  pro- 
cedure has  to  be  resorted  to  for  the  removal  of  this  band,  often  with 
most  unsatisfactory  results. 

The  history  of  the  cases  suffering  from  this  form  of  laceration 
would  indicate  that  the  occurrence  of  the  injury  is  due  to  the  position 
of  the  occiput  towards  the  sacrum.  It  is  very  rare,  for  bad  effects 
remain  after  laceration  either  backward  or  forward,  and  when  they 
do  occur  it  is  exceptional.  When,  however,  the  laceration  is  in  a 
lateral  direction,  and  extends  beyond  the  crown  of  the  cervix,  a  con- 
dition at  once  arises  which  will  defeat  all  the  reparative  efforts  of 
nature.  In  practice,  therefore,  we  have  to  deal  chiefly  with  the  con- 
sequences of  lateral  lacerations,  and  the  effects  are  more  marked 
when  the  lesion  is  double  than  when  confined  to  either  side.  When- 
ever the  rent  has  extended  to  the  vaginal  junction,  or  beyond,  there 
w^ill  exist  a  tendency  for  the  tissues  to  roll  out  from  within  the  uterine 
canal  as  soon  as  the  woman  assumes  the  upright  position.  The  poste- 
rior lip  of  the  cervix  naturally  catches  on  the  posterior  vaginal  wall, 
as  the  uterus  after  a  recent  delivery  is  larger  than  natural,  and  lower 
in  the  pelvis  from  its  increased  weight.  When  the  flaps  formed  by 
the  laceration  are  once  separated,  their  divergency  becomes  increased 
hy  the  anterior  lip  being  crowded  forward  in  the  axis  of  the  vagina. 
This  will  be  towards  the  vaginal  outlet,  in  the  direction  presenting 
the  least  resistance,  while  the  same  force  naturally  crowds  the  poste- 
rior lip  backwards  into  the  cul-de-sac.  From  thus  forcing  the  flaps 
apart,  a  source  of  irritation  is  at  once  established,  which  arrests  the 
involution  of  the  organ.  The  angle  of  laceration  soon  becomes  the 
seat  or  starting  point  of  an  erosion,  which  gradually  extends  over  the 
everted  surfaces.     With  the  increased  size  and  additional  weight  of 


460  DIAGNOSIS    AND    TREATMENT    OP 

the  uterus,  induced  by  congestion,  the  tissues  gradually  roll  out  as 
far  as  the  neighborhood  of  the  internal  os.  As  the  laceration  fre- 
quently occurs  in  consequence  of  rapid  labor,  or  from  its  having  been 
necessary  to  apply  the  forceps  or  to  use  traction,  the  perineum  is  fre- 
quently ruptured.  With  a  want  of  the  proper  support,  and  with  the 
uterus  enlarged,  prolapse  must  occur  so  that  the  organ  will  lie  on  the 
floor  of  the  pelvis,  with  frequently  some  degree  of  retroversion.  The 
vagina  can  now  not  only  not  regain  its  natural  size,  on  account  of  the 
prolapse,  but  it  becomes  still  more  dilated,  as  the  uterus,  from  a  want 
of  support,  continues  to  advance  like  a  wedge  towards  the  vaginal 
outlet. 

Sometimes  the  laceration  heals  while  the  woman  remains  in  bed 
after  her  labor,  but  when  she  gets  up,  the  surfaces  soon  become  the  seat 
of  an  extensive  erosion,  which  bleeds  readily.  As  the  uterus  begins 
to  increase  in  size,  a  profuse  cervical  leucorrhoea  follows,  and,  in 
consequence  of  a  frequent  show,  the  patient  seeks  relief.  She  will 
state  her  inability  to  stand  with  comfort,  complaining  of  a  continual 
backache,  with  pains  down  her  limbs,  sometimes  irritation  of  the 
bladder,  and,  as  a  rule,  marked  nervous  disturbance. 

Until  recently,  this  condition  of  laceration  was  universally  mistaken 
for  ulceration,  and  sometimes  for  the  early  stages  of  epithelioma, 
and  for  corroding  ulcer  of  the  uterus.  To  heal  this  "ulceration" 
would  long  baffle  every  mode  of  treatment,  or,  if  any  improvement 
took  place  in  the  patient's  condition  after  a  protracted  rest  in  the  re- 
cumbent position,  a  relapse  would  follow  again  and  again,  Avith  every 
attempt  at  exercise.  Such  a  case  passed  from  one  physician  to 
another,  until  eventually  the  leucorrhoea  ceased,  and  the  pi-ofuse 
menstruation  diminished  as  the  surfaces,  from  the  frequent  application 
of  caustics  or  the  cautery,  became  cicatricial  in  character.  Never- 
theless, a  woman  in  this  condition  gradually  became  a  confirmed 
invalid,  while  the  hypertrophy  of  the  uterus  remained,  and  from  im- 
pairment of  her  general  health  the  nervous  element  became  most 
prominent. 

Where  such  a  case  has  been  left  more  to  the  reparative  powers  of 
nature,  the  mucous  follicles  Avill  be  found  to  have  gradually  under- 
gone cystic  degeneration.  These  little  bodies  can  be  felt  like  small 
shot  imbedded  in  countless  numbers  within  the  tissues  of  the  cervix. 
They  become  distended,  rupture,  and  gradually  empty  themselves, 
by  which  the  follicles  are  destroyed  and  their  cavities  disappear  by 
contraction.     At  first  the  cervix  was  rather  hypertrophied  from  the 


LACERATIONS  OF  THE  CERVIX  UTERI.         461 

filling  of  these  cysts,  and  as  the  inflammation  and  enlargement  of  the 
follicles  extended  within  the  canal,  the  extent  of  mucous  membrane 
thus  rolled  out  greatly  increased.  The  cervix,  however,  and  fre- 
quently the  uterus  itself,  became  gradually  atrophied  from  the  pressure 
exerted  at  first  by  the  enlargement  of  the  cysts,  and  afterwards  by 
the  contraction  following  their  rupture.  Occasionally  the  atrophy  is 
I  confined  to  one  flap,  and  when  thus  limited  it  is  generally  to  the  ante- 
rior one. 

Eventually,  when  nature  has  been  thus  left  to  aid  herself,  the 
woman  will  frequently  cease  to  menstruate  at  rather  an  early  period 
in  life,  and  will  then  gradually  recover  her  health.  Unfortunately, 
however,  when  the  disease  has  existed  so  long  as  to  induce  a  condition 
of  profound  anaemia,  there  remains  no  power  in  reserve  to  aid  in 
bringing  about  a  reaction,  and  phthisis  becomes  developed.  Then, 
again,  a  woman  in  robust  health  may  be  able  so  far  to  repair  the 
damage  as  to  give  birth  to  a  number  of  children  after  the  injury. 
She  will  manage  to  hold  her  position  in  good  health  for  years,  not- 
withstanding frequent  menstrual  hemorrhages  and  a  wasting  leucor- 
rhoea  between  the  pregnancies.  But,  finally,  a  change  of  life  is 
completed,  when  epithelioma  springs  into  existence  from  the  seat  of 
the  old  injury  as  a  product  of  perverted  nutrition. 

Finally,  in  closing  this  description  of  the  difi"erent  forms  of  lacera- 
tion, we  must  refer  to  one  from  within  outwards,  where  the  laceration 
does  not  extend  through  the  thickness  of  the  cervix.  These  are  oc- 
casionally met  with,  and  it  is  often  exceedingly  difficult  to  demonstrate 
that  a  laceration  has  taken  place,  although  all  the  bad  effects  of  the 
lesion  are  easily  recognized.  It  would  seem  as  if  partial  laceration 
took  place  from  the  internal  os  downward,  on  different  sides,  through 
the  mucous  membrane  and  deeper  tissues,  Avithout  extending  to  the 
vaginal  surface  of  the  cervix,  making  folds  not  unlike  those  between 
the  ribs  of  a  partially  opened  umbrella,  which  disappear  when  it  is 
fully  opened  out.  Through  the  patulous  os  and  canal  the  mucous 
membrane  is  seen  prolapsed,  and  its  appearance  is  like  that  pre- 
sented after  dilating  Avith  a  sponge  tent  a  partial  contraction  of 
the  canal  which  had  taken  place  above,  but  had  not  yet  extended 
to  the  external  os.  The  cervix  is  frequently  but  little  enlarged  in 
diameter,  but  its  walls  are  seen  to  be  thinner  than  natural.  The 
cervical  discharge  is  most  profuse  and  tenacious.  The  menstrual  flow 
remains  too  free,  and  is  often  irregular,  and  the  uterus  is  found  larger 
than  normal. 


462 


DIAGNOSIS    AXD    TREATMENT    OF 


After  labor,  the  whole  organ  being  in  a  state  of  fatty  degeneration 
and  the  tissues  of  the  neck  soft,  these  flaps,  in  a  double  laceration, 
flatten  against  the  posterior  wall  of  the  vagina  or  floor  of  the  pelvis, 
so  that  all  appearance  of  laceration  becomes  lost.  So  perfect  is  the 
deception  that  it  is  frequently  impossible  for  any  one  not  familiar 
with  the  condition  to  recognize  the  existence  of  a  laceration  by  an 
ocular  examination  alone.  If  a  patient  be  placed  on  the  back,  and  a  ' 
digital  examination  made,  the  true  condition  can  be  easily  appreciated. 
When  there  is  simple  hypertrophy  of  the  uterus  the  finger  can  easily 
ascertain  that  the  body  of  the  uterus  above  is  as  large  as  the  cervix 
below.  But  with  double  laceration  of  the  cervix,  when  the  finger  is 
passed  up  behind  the  uterus  into  the  cul-de-sac,  or  in  front,  it  Avill 
be  found  that  the  cervix  is  much  larger  than  the  body.  The  rela- 
tive size  of  such  a  cervix  to  the  body  of  the  uterus  is  about  that  of 
the  top  of  a  half-groAvn  mushroom  to  its  stem.  If  the  patient  be 
placed  on  the  side,  and  the  speculum  introduced  to  bring  the  cervix 


Fis.  80. 


Fig.  81. 


Internal  laceration  of  the  cervix. 


Unilateral  laceration,  producing 
obliquity  of  the  uterus. 


into  view,  these  flaps  can  be  rolled  in.  By  seizing  the  anterior  and 
posterior  lips  of  the  cervix  with  a  tenaculum  in  each  hand,  and  then 
bringing  them  into  apposition,  the  inverted  portion  will  roll  in  toward 
the  canal.     The  shape  of  the  neck  will  then  be  represented  by  the 


LACERATIONS  OF  THE  CERVIX  UTERI.         463 

dotted  line  in  Fig.  80,  and  it  will  be  found  that  its  size  is  but  little 
larger  than  natural. 

When  the  laceration  has  been  complete,  but  confined  to  one  side, 
the  rolling  out  is  not  so  extensive,  nor  is  the  apparent  size  of  the 
cervix  so  large  as  in  the  previous  condition,  but  it  is  as  difficult 
often  at  first  sight  to  detect  the  injury.  A  partial  obliquity  of  the 
uterus  in  the  pelvis  is  thus  produced  by  crowding  the  cervix  towards 
the  uninjured  side,  and  this  surface  and  the  flattened  lacerated  por- 
tions may  present  a  common  plane  to  the  posterior  wall  of  the  vagina 
on  which  it  rests.  As  the  flaps  separate,  the  two  edges  and  the 
uninjured  side  form  a  tripod,  with  two  legs  shorter  than  the  third 
one,  so  that  the  fundus  must  necessarily  be  tilted  toward  the  injured 
side  (see  Fig.  81).  Cellulitis  is  a  most  common  result  of  this 
accident,  and  is  generally  situated  between  the  folds  of  the  broad 
ligament  on  the  side  of  the  laceration.  The  effect  of  the  cellulitis 
is  to  shorten  the  ligament,  and  the  fundus  will  be  fixed  towards 
the  injured  side.  This  causes  the  parts  which  have  been  torn  down 
to  the  vaginal  junction,  or  beyond,  to  project  into  the  passage,  and 
as  they  are  covered  by  a  reflexion  of  the  vaginal  tissue  over  this 
part  of  the  uterine  body,  just  above  the  terminating  point  of  the 
laceration  (see  Fig.  81),  the  effect  to  the  eye  is  a  length  of  cervix 
on  that  side  equal  to  the  uninjured  portion.  The  apparent  os  is 
always  more  patulous  than  in  health,  and  this  condition  is  readily 
accounted  for  from  the  evident  existence  of  disease  within  the  uterine 
canal.  Moreover,  the  deception  is  still  maintained  by  the  passage 
of  the  sound  in  the  median  line  to  the  fundus,  for  its  use  gives  no 
indication  of  the  true  condition.  The  explanation  is  that  the  sound 
passes  through  a  patulous  os,  along  the  angle  of  the  rent  on  one  side 
of  the  cervix,  to  the  horn  of  uterine  canal  on  the  opposite  side.  As 
is  shoAvn  in  Fig.  81,  these  two  points  are  brought,  by  the  abnormal 
position  of  the  uterus,  into  line  with  the  axis  of  the  vagina.  So  de- 
ceptive is  the  condition,  that  I  have  been  frequently  consulted  as  to  the 
propriety  of  amputating  an  enlarged  or  elongated  cervix,  when  if  a 
small  portion  only  of  the  apparent  enlargement  had  been  removed, 
the  peritoneal  cavity  would  have  been  opened.  The  cervix  is  never 
so  large  as  it  seems  to  be,  and  the  line  of  junction  with  the  vagina  is 
equally  deceptive.  It  is,  therefore,  a  wise  procedure,  in  any  doubtRxl 
case,  to  place  the  patient  for  examination  on  her  knees  and  elbows. 
On  the  introduction  of  the  speculum  the  vagina  becomes  distended  by 
atmospheric  pressure,  and  by  the  aid  of  gravity  the  uterus  is  brought 
into  its  proper  position.     The  true  line  of  junction  with  the  vagina 


464  DIAGNOSIS    AND    TREATMENT    OF 

will  be  then  well  marked,  and  only  the  actual  length  of  the  cervix 
will  project  above  the  vaginal  surface.  In  a  case  of  laceration  on 
one  side,  extending  to  or  beyond  the  vaginal  junction,  the  fissure  will 
be  detected  Avithout  difficulty,  in  this  knee-elbow  position.  By  the 
weight  of  the  uterus  its  axis  in  the  pelvis  will  be  brought  in  line  to 
correspond  with  that  of  the  vagina,  so  that  the  depth  of  the  cleft 
through  the  tissues  can  be  appreciated  at  a  glance. 

Treatment. 

The  chief  purport  of  treatment  is  to  bring  about  union  of  the  lace- 
rated surfaces,  and  the  question  naturally  presents  itself  as  to  the 
circumstances  under  which  an  operation  is  called  for.  I  would  state 
that  in  every  instance  where  the  condition  is  evident,  and  where  en- 
largement of  the  uterus  still  remains,  or  where  the  woman  suffers 
from  neuralgia,  I  consider  an  operation  necessary,  notwithstanding 
the  parts  may  have  completely  healed. 

Every  case  of  laceration  is  benefited  by  some  preparatory  treat- 
ment previous  to  the  operation.  The  uterus,  from  its  increased  weight, 
and  Avhile  resting  on  the  floor  of  the  pelvis,  will,  by  traction  on  the 
cellular  or  connective  tissue,  obstruct  the  circulation  sufficiently  to 
produce  not  only  increased  congestion  of  the  organ  itself,  but  also 
of  the  neighboring  tissues.  To  give  tone  to  the  vessels  and  relieve 
the  congestion,  large  hot-water  vaginal  injections  must  be  used  once 
or  twice  a  day,  until  all  tenderness  on  pressure,  Avhich  may  have  been 
detected  by  means  of  the  finger,  has  disappeared.  To  hasten  this  the 
frequent  application  of  iodine  to  the  abdominal  wall,  or  a  small 
blister,  is  of  great  benefit  when  made  over  the  seat  of  the  cellu- 
litis. If  a  broad  ligament  has  become  thickened  and  shortened  from 
the  previous  inflammation,  the  whole  weight  of  the  uterus  Avill  be 
thrown  upon  it  whenever  the  Avoman  is  in  the  upright  position.  As 
has  been  already  stated,  an  old  cellulitis  is  frequently  kept  up,  as  it 
were,  from  this  single  source  of  irritation  not  being  appreciated. 
One  of  the  first  steps  to  be  taken  in  the  treatment  of  this  condition 
is  to  fit  some  instrument  which  will  lift  the  organ  from  the  floor  of  the 
pelvis.  Where  a  closed  lever  pessary  can  be  used,  it  best  answers 
the  purpose,  since  it  can  remain  undisturbed.  The  uterus  must  be 
first  anteverted  by  means  of  the  index  finger  in  the  vagina,  and  the 
pessary  be  then  so  curved  as  to  hold  the  organ  in  this  position.  This 
is  important,  for  by  keeping  the  uterus  anteverted  the  flaps  cannot 
gape  apart  to  any  extent,  and  in  preventing  this  we  remove  a  source 


LACERATIONS  OF  THE  CERVIX  UTERI.         405 

of  irritation.  To  fit  the  pessary  properly  requires  some  jndgmcnt, 
for  if,  as  has  been  shoAvn,  the  uterus  be  lifted  too  high  in  the  pelvis, 
we  again  put  the  shortened  broad  ligament  on  the  stretch  and  produce 
a  condition  we  wish  to  avoid.  The  best  guide  is  the  sense  of  relief 
felt  by  the  patient,  and  her  unconsciousness  of  the  presence  of  the 
instrument.  Frequently  it  is  necessary  to  make  the  pessary  more 
narrow  where  it  comes  in  the  neighborhood  of  the  thickened  broad 
ligament.  In  this  condition,  if  the  sides  be  left  straight,  as  is  usual, 
the  instrument  will  cause  lateral  pressure  on  the  vaginal  walls, 
and  so  much  irritation  that  it  may  have  to  be  abandoned.  We 
may  then  employ  the  hard  rubber  pessary,  which  was  described  in 
the  chapter  on  Cellulitis,  or  the  India-rubber  inflated  ring  pessary. 
The  advantage  of  the  latter  insti'ument  is  that  if  it  is  introduced  with 
the  flaps  of  the  laceration  in  contact,  and  the  uterus  anteverted,  they 
cannot  again  separate.  Any  downward  pressure  has  the  tendency  to 
crowd  the  cervix  toward  the  opening  in  the  centre  of  the  ring,  while 
the  aperture  is  not  large  enough  in  diameter  to  allow  any  portion  to 
become  strangulated.  The  instrument  should  be  by  no  means  the 
size  of  the  already  over-stretched  vagina,  for,  if  it  were,  it  would  but 
dilate  the  passage  the  more.  It  is  to  be  used  merely  as  a  temporary 
cushion ;  and  as  there  is  likely  also  a  laceration  of  the  perineum, 
which  would  allow  of  a  prolapse  of  the  vaginal  walls,  the  instrument 
must  be  kept  in  place  by  a  T  bandage. 

In  addition  to  the  vaginal  injections,  the  local  treatment  will  in- 
clude the  application  of  Churchill's  tincture  of  iodine,  about  twice  a 
week,  with  frequent  glycerine  dressings.  Or  tannin  and  glycerine  may 
be  applied  to  the  parts  every  other  day.  Glycerine  is  preferable  to 
water  as  a  vehicle,  since  it  increases  the  action  of  the  tannin,  and 
brings  about  capillary  contraction.  Where  the  surfaces  have  become 
covered  by  granulations  and  bleed  readily,  an  application  may  be 
made  about  once  a  week  of  the  subsulphate  of  iron,  or  Monsel's  salt. 
These  applications  should  be  made  just  after  the  vaginal  injections, 
and  after  removing  the  secretions  with  a  syringe  as  thoroughly  as  possi- 
ble. The  parts  can  then  be  well  dried  by  means  of  small  pieces  of  old 
linen  laid  between  the  flaps,  and  removed  as  the  application  is  made. 
It  is  advisable  to  separate  thoroughly  the  flaps  before  applying  the 
preparation  of  iron,  that  the  powder  may  be  dusted  over  the  Avhole 
denuded  surface.  But  after  the  application  has  been  made,  the  lips 
must  be  again  brought  together,  the  uterus  anteverted,  and,  Avhen 
possible,  the  patient  should  be  kept  in  the  horizontal  position  for 
several  hours  afterwards.  When  the  circumstances  are  such  that  the 
30 


466  DIAGNOSIS    AND    TREATMENT    OP 

patient  is  unable  to  keep  quiet  after  the  application,  it  is  a  good  plan 
to  place  in  the  posterior  cul-de-sac  a  proper  sized  pledget  of  damp 
cotton,  and  another  in  front  of  the  anterior  lip.  These  cotton  pledgets 
are  for  a  day  or  two  to  take  the  place  of  the  instrument,  which  would 
be  injured  by  contact  with  the  iron,  while  at  the  same  time  they  will 
protect  the  patient's  linen.  As  a  rule,  I  leave  the  tampon  undisturbed 
for  forty-eight  hours,  and  have  the  vaginal  injections  omitted  for  the 
same  length  of  time. 

After  a  double  laceration  of  the  cervix,  a  partial  constriction  is 
often  produced  in  the  neck  as  the  parts  cicatrize,  and  especially  is 
this  the  case  when  the  tear  has  passed  beyond  into  the  vaginal  tissue. 
This  is  often  suflficient  in  extent  to  obstruct  the  circulation  in  the  flaps 
when  aided  by  cystic  degeneration  of  the  mucous  follicles.  Conse- 
quently the  flaps  become  almost  strangulated ;  the  effect,  in  fact,  is 
similar  to  paraphimosis.  The  next  and  most  important  step  in  the 
preparatory  treatment  is  to  relieve  this  congested  condition  by  punc- 
turing the  cysts.  A  small,  lance-shaped  knife  is  needed  for  the  pur 
pose.  It  is  not  necessary  to  pick  out  each  individual  cyst.  The 
whole  lacerated  surface  may  be  gone  over  by  little  stabs  in  every 
direction,  and  the  point  of  the  instrument  will  penetrate  the  distended 
cysts  more  easily  than  it  will  enter  the  tissue  of  the  cervix. 
Scarcely  an  ounce  of  blood  will  be  lost  under  any  circumstances,  but 
from  emptying  the  cysts,  and  from  this  bleeding,  the  size  of  the  flaps 
will  be  greatly  reduced.  Churchill's  iodine  is  then  to  be  freely 
applied  over  the  surface  in  which  the  cysts  have  been  punctured. 
After  this  has  been  done,  the  flaps  are  to  be  brought  together  and 
kept  in  contact  by  a  portion  of  cotton  saturated  in  glycerine,  which 
will  ci'owd  the  neck  into  the  posterior  cul-de-sac.  These  scarifications 
are  to  be  repeated  again  and  again,  and  the  iodine  applied  from  time 
to  time  until  the  cysts  have  all  disappeared,  the  flaps  reduced  in  size, 
and  the  erosion  greatly  lessened  in  extent  or  healed.  I  have  fre- 
quently resorted  to  the  use  of  a  silver  wire,  passed  through  each  flap 
at  about  half  an  inch  from  the  edge  ;  by  twisting  the  two  ends 
until  the  lacerated  surfaces  are  brought  just  into  contact,  much  will 
be  gained  by  thus  temporarily  preventing  the  parts  from  rolling  out. 
This  plan,  however,  can  only  be  resorted  to  while  the  patient  remains 
quiet,  for  if-  she  were  exercising,  the  wire  would  soon  cut  out,  or  act 
as  an  irritant. 

If  the  operation  be  performed  after  the  different  sources  of  irrita- 
tion have  been  removed,  the  uterus  will  be  reduced  rapidly  in  size,  and 


LACERATIONS  OF  THE  CERVIX  UTERI. 


467 


the  patient  will  not  only  regain  her  health, 
but  will  remain  in  the  full  enjoyment  of  it 
afterwards.  So  long,  however,  as  there 
can  be  detected,  by  pressure  with  the 
finger,  any  tenderness  in  the  neighboring 
connective  tissue,  it  is  not  safe  to  operate. 
We  may  feel  fully  satisfied  that  a  certain 
amount  of  cellulitis  has  previously  existed, 
and  a  condition  is  still  remaining  which 
would  require  but  a  slight  provocation  to 
re-establish  the  inflammation. 

The  usual  mode  of  operating  is  to  place 
the  patient  on  the  left  side,  and  to  use 
Sims's  speculum,  or  some  other  perineal 
retractor,  to  bring  the  parts  into  view. 
The  operation  can  sometimes  be  performed 
on  the  back,  when  the  vaginal  outlet  is 
laro;e,  since  the  uterus  is  then  so  low  that 
it  can  be  readily  drawn  outside  and  re- 
turned after  the  operation.  But  the  left 
side  has  this  advantage,  that  while  the 
patient  is  in  this  position,  there  can  be 
less  rolling  out  of  the  tissues  than  in  any 
other,  except  in  the  knee-elbow  position. 

The  first  step  is  to  bring  the  flaps  to- 
gether in  apposition,  and  while  they  are 
lifted  up  by  means  of  the  double  tenacu- 
lum in  the  hands  of  an  assistant,  the  ute- 
rine tourniquet.  Fig.  82,  is  to  be  slipped 
over  the  cervix  below  the  point  of  vaginal 
junction  and  tightened.  The  object  of 
this  instrument  is  to  control  the  hemor- 
rhage during  the  operation,  as  it  is  some- 
times excessive.  Until  I  had  this  instru- 
ment made,  I  used  a  portion  of  twisted 
wire,  such  as  is  usually  furnished  for  the 
^craseur,  the  two  ends  of  which  were 
passed  through  a  canula.  The  loop  was 
slipped  over  the  neck  of  the  uterus,  while  uterine  tourniquet. 

being  held  by  an  assistant,  and  tightened 
bv  sliding  the  canula  down  the  wires  held  in  the  other  hand. 


As 


468 


DIAGNOSIS    AND    TEEATMEXT    OF 


soon  as  the  cervix  was  compressed  as  much  as  possible  by  this  means, 
the  ends  of  the  wire  "were  bent  back,  and  several  times  wrapped  around 
the  end  of  the  canula,  so  that  they  could  not  slip.  The  instrument 
above  mentioned  has,  instead  of  the  wire,  a  portion  of  watch  spring 
passed  through  a  canula,  and  in  the  handle  is  the  double  ratchet 
of  the  ecraseur  to  tighten  the  loop  about  the  cervix.  Just  before 
constricting  the  neck  with  either  instrument,  I  take  the  precaution  to 
draw  up  Avith  a  tenaculum,  through  the  loop,  sufficient  vaginal  tissue 
all  around  the  cervix  to  enable  the  flaps  to  be  brought  together  easily. 
The  fold  thus  formed  renders  the  instrument  less  likely  to  slip  over 
the  cervix  Avhen  it  has  become  reduced  in  size  from  the  escape  of 
blood  during  the  operation. 

Until  recently  I  regarded  this  uterine  tourniquet  as  essential  in 
every  operation  for  closing  a  lacerated  cervix.  I  now  confine  its  use 
entirely  to  operations  when  the  tissues  of  the  cervix  are  unusually 
soft,  since  1  have  learned  from  experience  that  the  loss  of  blood  is 
likely,  in  such  cases,  to  be  very  great.  But  under  ordinary  circum- 
stances I  have  found  that  the  administration  of  a  large  hot-water 
vaginal  injection,  just  before  the  operation,  will  so  far  lessen  the 
bleeding  that  the  tourniquet  can  be  dispensed  with. 

After  separating  the  flaps  fully,  the  surfaces  which  have  been  torn, 
in  a  double  laceration,  are  to  be  freely  denuded  from  one  lip  to  the 
other,  leaving  a  broad  undenuded  tract  in  the 
centre,  from  before  backward,  which  is  to  form 
the  continuation  of  the  uterine  canal  from  the 
OS.  This  undenuded  portion  on  each  flap  is 
made  to  correspond  with  that  on  the  opposite 
side,  and  should  widen  gradually  from  the  edge 
of  the  uterine  canal  towards  the  outer  edge  of 
the  divided  portion  of  the  cervix,  as  shown  in 
Fig.  83.  Therefore,  when  the  two  flaps  are 
brought  together,  the  new  canal  through  the 
cervix  will  be  trumpet-shaped.  As  the  uterus 
gradually  returns  to  its  normal  size  (and  the 
change  will  be  the  most  marked  in  the  cervix), 
this  new  canal  will  become  of  a  natural  and 
uniform  diameter  throughout.  To  make  this 
canal  of  a  proper  size,  we  must  be  guided  by 
the  amount  of  hypertropliy  in  the  flaps.  It  must  bear  some  relation 
to  the  increased  size  of  the  flaps,  and  the  trumpet  shape  is  necessary, 


FifiT.  83. 


Lacerated  cervix,  after  denn 
datiou. 


LACERATIONS    OF    THE    CEllVIX    UTERI. 


400 


since  the  hypertrophy  increases  in  deji;ree  from  the  bottom  of  the 
laceration  towards  the  outer  edges  of  the  flap. 

Either  the  scissors  or  the  scalpel  may  be  used  to  freshen  the 
surfaces,  but  I  prefer  the  scissors,  for  the  greater  rapidity  with 
which  the  tissues  can  be  removed  with  them.  It  is  necessary  when 
freshening  the  surfaces  to  remove  very  superficially  the  tissues  near 
the  outer  angles  of  the  fissure,  just  at  the  vaginal  junction,  unless 
the  laceration  should  liave  been  a  very  extensive  one.  The  circular 
artery,  owing  to  its  elasticity  and  its  position  in  loose  connective  tissue, 
is  seldom  ruptured  when  a  laceration  of  ordinary  extent  takes  place. 
But  as  the  parts  contract  after  cicatrization,  it  is  frequently  left  just 
at  the  termination  of  the  angle  of  the  fissure  Avith  the  vaginal  tissues. 
When  the  tissues  are  dense,  I  sometimes  have  to  use  a  scalpel  to 
denude  the  angle  at  the  bottom  of  the  laceration,  when  confined  to 
one  side.  We  frequently  meet  with  cases  where  nature  has  attempted 
to  repair  the  injury,  and  to  prevent  the  gaping  of  the  flaps,  in  a  double 
laceration,  by  filling  in  the  angle  on  each  side  by  granulations  as  the 
parts  have  healed.  The  result  is  that  a  dense  cicatricial  plug  (C, 
Fig.  84)  remains.  When  this  condition  exists,  there  is  always  much 
disturbance  of  the  nervous  system,  and 
frequently  it  is  the  exciting  cause  of 
neuralgia  in  other  parts  of  the  body 
through  the  medium  of  the  sympathetic. 

It  is  important  to  draw  particular  at- 
tention to  this  condition,  that  its  exist- 
ence may  not  only  be  recognized,  but 
the  necessity  for  its  removal  fully  ap- 
preciated. Apparently  the  limit  of  the 
laceration  is  along  the  dotted  line  T, 
and  the  extent  of  injury  seems  very 
superficial,  when,  in  fact,  it  may  have 
been  very  deep.  When  this  surface  only 
has  been  denuded  and  the  sutures  intro- 
duced, the  operator  will  be  surprised  at 
the    difiiculty   experienced   in   bringing 

the  parts  properly  together.  Let  the  reader  place  an  ordinary  sized 
wooden  spool  in  the  angle  between  two  of  his  fingers  and  then  attempt 
to  bring  together  the  sides  of  these  fingers.  It  can  be  done  by  force, 
but  it  is  at  once  realized  that  the  circulation  becomes  obstructed ;  and 
so  the  lips  of  a  laceration  would  meet  with  similar  resistance  if 
this  cicatricial  plug  is  shut  up  between  them,  and  any  sutures  intro- 


Fig.  84. 


Cicatricial  plug  ia  a  lacei-ated  cervix. 


470  DIAGNOSIS    AND    TREATMENT    OF 

duced  through  them  woukl  be  likely  to  cut  out.  When  the  parts  have 
been  thus  closed,  shutting  up  this  mass  of  cicatricial  tissue,  there  will 
be  no  improvement  even  should  they  unite  perfectly.  The  uterus  will 
remain  quite  as  large  as  before,  and  frequently  will  even  increase 
in  size.  The  appearance  of  the  neck  will  show  that  the  circulation 
-is  obstructed,  and  as  nature  must  attempt  to  relieve  this  by  an  in- 
crease of  secretion  from  the  uterine  canal,  an  erosion  soon  forms.  A 
fresh  attack  of  cellulitis  is  not  an  unusual  occurrence,  since  the  posi- 
tion of  the  uterus  will  have  been  disturbed  to  an  unusual  degree,  in 
consequence  of  the  great  difficulty  experienced  in  the  introduction  of 
the  sutures  through  this  dense  tissue.  Finally,  there  will  be  a  marked 
increase  of  the  anaemia  and  the  neuralgia,  owing  to  the  additional 
irritation  to  the  nervous  system,  and  nutrition  becomes  still  further 
impaired.  The  only  remedy  is  to  remove  the  whole  mass  on  both 
sides  in  a  V-shape,  and  to  secure  the  surfaces  thus  made  with 
sutures,  as  in  the  operation  for  double  laceration.  But  one  precau- 
tion is  necessary,  and  that  is  to  disturb  the  position  of  the  uterus  as 
little  as  possible,  since  so  extensive  a  laceration  must  have  produced 
cellulitis  at  the  time  of  the  occurrence.  If  the  uterus  be  then 
dragged  down  at  the  operation,  the  force  of  the  traction  must  be  spent 
on  the  shortened  broad  ligament,  and  a  fresh  attack  of  cellulitis  will 
be  the  consequence. 

Under  other  circumstances,  when  the  case  has  been  of  long  standing, 
many  cysts  will  have  formed  and  ruptured,  from  which  cause  contrac- 
tion takes  place  along  the  edge  of  the  mucous  membrane  of  the  canal 
and  vaginal  surface.  The  effect  of  this  contraction  is  to  convert  the 
former  flat  sides  of  the  flaps  into  two  convex  surfaces  in  apposition 
with  each  other.  Were  we  simply  to  freshen  these  surfaces  in  a 
superficial  manner,  and  then  attempt  to  bring  them  together,  we 
would  fail  to  approximate  the  outer  edges  properly,  unless  the  sutures 
were  tAvisted  so  tight  that  they  would  cut  out.  This  tissue  is  cica- 
tricial, and  constitutes  so  dense  a  foreign  body  that,  were  we  to 
succeed  in  obtaining  union,  it  could  be  only  temporary,  for  the  pre- 
vious condition  would  soon  be  reproduced  through  want  of  vitality. 

Not  only  is  it  necessary  to  remove  entirely  this  projecting  surface, 
but  even  partially  to  excavate,  that  the  sides  of  the  flaps  may  be 
brought  into  close  contact  throughout,  when  the  sutures  have  been 
secured.  The  lines  A  B,and  C  D,  Fig.  85,  indicate  the  portion  to  be 
removed,  but  this  removal  is  not  to  extend  entirely  across  the  flap, 
for  if  this  were  done,  there  would  be  a  complete  closure  of  the 
cervical  canal.     Nor  is  the  removal  necessary  to  this  extent,  since  the 


LACERATIONS  OF  THE  CERVIX  UTERI 


471 


hypertro pined  portion  is  chiefly  that  part  -which  is  shown  in  Fig.  85, 
and  represents  the  amount  to  be  denuded. 

This  will  be  made  more  evident  by  reference  to  Fig.  86,  which  shows 
a  horizontal  plane,  as  it  were,  of  the  cervix.    Here  the  hypertrophied 


Fig.  85. 


Vig.  86. 


Diagram  of  surfaces  to  be  denuded. 


Cicatricial  hypertrophy  after  laceration. 

tissue  is  indicated  by  A  B,  C  D,  and  is  to  be  removed  to  the  bottom 
of  the  laceration,  along  the  dotted  lines,  so  that  the  lines  A  and  B,  C 
and  D,  can  be  brought  together  by  sutures.  The  same  precaution 
in  regard  to  pulling  the  uterus  down,  as  was  urged  in  the  previous 
condition,  must  be  observed  here  also,  through  fear  of  exciting  cellu- 
litis. 

The  cervix  is  sometimes  lacerated  in  a  bifid  form,  or  into  three,  and 
even  four  sections.  Were  we  to  denude  between  each  cleft,  and  then 
attempt  to  bring  all  these  flaps  together,  the  result  would  be,  in  all 
probability,  a  failure,  since  the  traction  in  opposite  directions  would 
cause  the  sutures  to  cut  out. 

One  or  more  of  these  flaps  is  usually  hypertrophied  and  much  out 
of  proportion  to  the  rest,  so  that  it  would  be  difficult  to  approximate 
the  surfaces  properly.  But  a  glance  at  Fig.  87  will  show  that  on 
removing  a  small  segment,  by  a  V-shaped  incision,  it  would  be  easy 
afterwards  to  bring  together  the  freshened  surfaces,  so  that  both  the 
cervix  and  canal  would  be  restored  to  a  normal  size. 

"When  lacerated  into  four  sections  I  have  removed  on  each  side  a 
segment,  and  then  brought  the  remaining  flaps  together  as  in  a  double 
laceration. 


472  DIAGNOSIS    AND    TREATMENT    OF 

With  a  knowledge  of  this  prinoiple,  it  will  require  but  little  study 
of  any  individual  case  to  realize  almost  at  a  glance  the  proper  course 
to  pursue. 

Fi?.  87. 


Bifid  laceration  of  the  cervix. 


When  it  is  safe  to  do  so,  the  process  of  freshening  the  surfaces  is 
very  much  facilitated  by  drawing  the  uterus  gently  down  towards 
the  vaginal  outlet,  and  then  having  the  organ  steadied  by  a  strong 
tenaculum  in  the  hands  of  an  assistant.  The  nearest  portion,  or  that 
which  is  the  lowest,  should  be  removed  first,  since  by  doing  so  the 
view  is  less  obstructed  by  blood  running  over  the  surface.  The  por- 
tion to  be  removed  is  to  be  hooked  up  with  a  small  tenaculum,  and 
the  strip  kept  on  the  stretch,  while  it  is  being  separated,  and  if  possi- 
ble it  should  be  removed  in  a  single  piece  from  the  side  of  one  flap  to 
the  other.  This  is  the  best  plan  to  insure  the  denudation  of  the  whole 
surface  when  the  oozing  of  blood  is  at  all  free.  With  the  use  of  either 
the  knife  or  scissors,  the  freshened  surfaces  should  be  made  as  smooth 
as  possible,  and  uniform  in  extent.  The  best  results  are  obtained 
when  we  get  union  by  the  first  intention,  but  to  gain  this  it  is  neces- 
sary that  the  parts  should  be  approximated  with  some  degree  of  accu- 
racy, for  a  projecting  edge,  left  to  heal  by  granulation,  cicatrizes  and 
afterwards  contracts.  The  presence  of  a  cicatricial  cord  across  the 
cervix  may  give  rise  to  as  much  disturbance  as  the  original  diffi- 
culty. 

When  the  injury  has  been  of  long  standing,  and  the  tissues  have 
become  dense,  the  chief  difficulty  in  the  operation  is  experienced  in 
passing  the  needles.  The  short  round  needle,  Avhich  I  was  the  first 
to  use  for  operations  about  the  vagina,  has  the  advantage  of  making 
only  a  punctured  wound.  When  the  suture  is  introduced,  it  so  fully 
occu[)ics  the  tract,  as  was  stated  when  treating  of  operations  on  the 
perineum,  that  there  is  little  danger  of  oozing  of  blood,  which  is  of 


LACERATIONS  OF  THE  CERVIX  UTERI.         473 

frequent  occurrence  after  the  use  of  the  needle  with  a  cutting  edge. 
But  the  more  dense  and  indurated  the  tissue,  the  less  vascular  will  be 
the  parts.  Under  these  circumstances,  the  lance-pointed  needle,  being 
easier  of  introduction,  answers  best  for  the  purpose  ;  but  if  the  tissues 
are  soft,  the  round  needle  should  be  used.  Three  or  four  sutures 
are  required  for  each  side,  if  the  laceration  be  extensive  or  double. 
They  should  be  introduced,  as  illustrated  in  Fig.  83,  from  A,  at  the 
outer  portion  of  the  flap,  to  rt,  at  the  edge  of  the  surface  which  is  to 
form  the  canal,  and  then,  from  witliin  outwards,  through  the  other  flap 
from  h  to  B,  so  as  to  correspond.  The  chief  object,  however,  is  to  make 
an  accurate  approximation  along  the  vaginal  surface,  since  the  edges 
forming  the  canal  will  be  kept  in  contact  much  as  the  inner  edges  of  the 
staves  of  a  barrel  are  by  a  properly  fitted  hoop.  When  the  bleeding 
has  been  troublesome,  it  is  advisable  to  pass  the  first  suture  through 
the  vaginal  tissue,  a  short  distance  below  the  angle  of  the  laceration. 
The  circular  artery,  or  its  branch,  from  which  the  oozing  generally 
comes,  will  be  secured  by  this  plan.  When  the  laceration  is  a  double 
one,  the  sutures  for  the  opposite  side  must  all  be  introduced  before 
securing  those  already  passed,  or  great  difiiculty  will  be  experienced; 
and  should  there  be  an  unusual  amount  of  bleeding,  it  can  be  arrested 
by  twisting  the  interrupted  suture  nearest  to  the  bottom  of  the  angle. 
Before  doing  so,  however,  it  would  be  better,  where  the  tourniquet 
has  been  used,  to  see  if  the  hemorrhage  cannot  be  controlled  by  tight- 
ening this  instrument,  as  it  may  have  become  loosened  in  consequence 
of  the  shrinkage  of  the  neck  after  the  escape  of  the  blood  which  was 
confined  within  the  tissues  when  the  instrument  was  first  applied. 

The  mode  of  securing  the  sutures  by  twisting  has  been  fully  de- 
scribed under  the  head  of  "  silver  sutures  and  mode  of  introduction." 
If  the  sutures  are  properly  bent  over,  so  as  to  lie  close  to  the  surface 
of  the  neck,  and  are  cut  ofi"  at  half  an  inch  in  length,  they  may  remain 
undisturbed  for  an  indefinite  time  without  causing  iri'itation.  I  have 
met  with  several  cases  where  the  bleeding  was  profuse  on  removing 
the  tourniquet  after  completion  of  the  operation,  but  in  each  instance 
it  was  arrested  promptly  by  an  injection  of  hot  water  administered 
before  the  effects  of  the  anaesthetic  had  passed  off". 

To  close  a  laceration  on  one  side  only,  is  rather  more  difficult  than 
if  it  were  a  double  one.  This  is  in  consequence  of  the  difficulty  of 
properly  denuding  the  angle,  and  of  freeing  it  from  cicatricial 
tissue.  The  double  tenaculum  in  the  hand  of  an  assistant  will  be 
found  useful  to  keep  the  flaps  apart,  and  to  steady  the  uterus  while 
the  angle  is  being  denuded  with  either  scissors  or  scalpel  (see  Fig.  88). 


474 


DIAGNOSIS    AXD    TREATMENT    OF 


It  is  well  to  institute  some  preparatory  treatment  in  cases  of  multiple 
or  stellate  laceration,  Fig.  89,  but,  as  a  rule,  little  benefit  -will  result 
except  from  the  use  of  strong  solution  of  chromic  acid  or  some  other 
agent  which  will  cause  the  canal  to  contract.     If  this,  however,  were 

Fig.  88. 


Double  tenaeulnin,  separating  tlie  flaps  of  a  laceration. 


all  there  is  to  be  accomplished,  the  use  of  the  cautery  would  be  the  most 
prompt  and  efficient  means,  not  only  to  cause  the  canal  to  contract, 
but  to  heal  rapidly  the  erosion,  thus  checking  the  profuse  cervical 
leucorrhoea  and  free  menstnial  flow.  But  after  having  accomplished 
this  bv  such  means,  it  is  evident  that  the  mucous  membrane  will  be 
entirely  changed  in  character,  if  it  is  not  destroyed. 

An  operation  will  be  necessary,  should  the  injury  be  so  extensive 
as  not  to  yield,  after  a  reasonable  time,  to  the  application  of  iodine, 
the  spirits  of  turpentine,  the  acetic  solution  of  cantharides,  or  any 
other  remedy  which  might  be  employed  for  the  purpose  of  bringing 
about  a  new  action  in  the  prolapsed  and  lacerated  tissue,  without,  at 
the  same  time,  destroying  its  integrity.  The  operation  in  itself  is 
simple,  the  cervix  being  divided  Avith  a  pair  of  scissors,  on  each  side, 
to  the  vaginal  junction,  thus  bringing  about,  as  it  were,  a  double 
laceration.  It  will  then  be  necessary  to  increase  the  area  of  the 
denuded  surfaces  by  removing  a  sufficient  amount  of  tissue  on  each 
side,  so  that  the  canal  will  be  restored  to  a  normal  size  when  the 
flaps  have  been  brought  together  with  sutures. 

The  subsequent  treatment  will  be  the  same  for  any  form  of  lacera- 
tion, and  will  consist  in  confining  the  patient  to  bed  for  two  weeks 
after  the   operation,   for  fear   that   the  flaps   may    separate,  while 


LACERATIONS  OF  THE  CERVIX  UTERI, 


475 


perfect  rest  in  the  horizontal  position  will  facilitate  the  decrease  in 
tiie  size  of  the  uterus. 

There  will  generally  be  no  necessity  for  keeping  the  bowels  con- 
stipated, nor  for  restricting  the  diet,  provided  its  quantity  and  quality 
be  suitable  for  one  remaining  in  bed.  The  bladder  should  be  emptied 
by  means  of  a  catheter,  or  a  bed-pan  should  be  used.    But  when  the 

Ficr.  89. 


Multiple,  or  stellate,  laceration  of  the  cervix. 

urine  has  been  passed  on  the  bed-pan,  a  little  warm  water  should  al- 
ways be  injected  into  the  vagina  immediately  afterwards  to  prevent 
any  urine  which  may  have  entered  the  canal  from  remaining  in  con- 
tact with  the  uniting  surfaces.  In  addition,  on  the  second  or  third 
day  after  the  operation,  a  vaginal  injection  of  tepid  water  should 
be  given  once  a  day,  or  night  and  morning,  if  there  should  be  much 
discharge. 

The  sutures  are  generally  removed  on  the  seventh  day,  and  some 
care  is  needed  in  withdrawing  them,  as  the  line  of  union  is  frequently 
weakened  by  carelessness  in  doing  so.  When  the  patient  is  placed  on 
the  left  side,  and  the  cervix  has  been  brought  into  view  by  the  use  of 
Sims's  speculum,  the  lower  portion  of  the  loop  should  be  cut  close  to 
the  end  of  the  twist,  and  then  withdrawn.  Each  portion  of  the  loop 
will  then  bind  together  the  parts  until  it  has  been  removed,  while  if 
we  should  cut  the  upper  part  and  make  traction,  the  surfaces  would 
be  drawn  asunder.  It  is  best  to  remove  first  the  suture  nearest  to  the 
vaginal  junction,  for  if  there  should  be  any  tendency  to  gape  in  the 
line,  the  others  can  be  left  for  several  days  longer,  so  that  the  ununited 
portion  may  heal  by  granulation. 


476  DIAGNOSIS    AND    TEEATMEXT    OF 

It  is  of  great  importance  that  the  patient  should  not  sit  up  in  bed 
for  ten  or  twelve  days  after  the  operation.  A  portion  of  the  line  is 
verv  apt  to  separate  after  the  sutures  have  been  removed,  if  this  be 
neglected.  Moreover,  to  get  up  vrould  expose  her  to  the  effects  of 
cold,  and  cellulitis,  if  it  has  existed,  is  likelv  to  recur  on  a  slight  pro- 
vocation. 

When  retroversion  has  existed,  and  a  pessary  has  been  used,  it  is 
best,  as  a  rule,  to  remove  it  at  the  time  of  the  operation,  and  to  replace 
the  instrument  onlv  when  the  patient  begins  to  stand  on  her  feet. 
If  the  uterus  is  left  anteverted,  as  it  should  be  after  the  operation, 
and  then  replaced  by  the  finger  if  necessary  when  the  sutures  are 
removed,  it  will  generally  remain  in  this  position  while  the  patient  is 
in  bed.  But  should  the  uterus  be  allowed  to  become  retroverted  again, 
it  will  be  crowded  lower  into  the  vagina  as  soon  as  the  patient  begins  to 
exercise.  Traction  will  be  at  once  made  by  the  walls  of  the  vagina 
on  the  anterior  and  posterior  flaps.  The  result  will  be  that  the 
original  condition  will  be  reproduced.  Or,  on  account  of  obstruc- 
tion to  the  circulation,  the  hypertrophy  of  the  uterus  will  increase, 
and  an  erosion  will  soon  form  on  the  cer\ix  which  will  ultimately 
extend  to  the  uterine  canal.  This  most  important  feature  in  the  treat- 
ment, viz..  the  necessity  for  placing  the  uterus  in  a  proper  position, 
is  frequently  overlooked ;  it  is  not  only  necessary  preparatory  to  the 
operation,  but  it  is  a  very  essential  means  for  obtaining  beneficial 
results  afterwards.  After  the  sutures  have  been  removed,  the  uterus 
will  decrease  rapidly  in  size  if  there  exists  no  cause  of  irritation  to 
arrest  its  progress.  Therefore  to  favor  this  change  an  early  resort  to 
some  mechanical  support  is  addsable,  to  lift  the  uterus  from  the  floor 
of  the  pelvis,  and  to  keep  it  anteverted  if  possible.  The  instrument 
used  previous  to  the  operation  will  now  be  found  too  large,  but  in 
any  event  a  smaller  one  should  be  employed  if  possible,  that  the 
vagina  may  return  to  its  natural  size  from  the  over-stretched  condition 
induced  by  the  prolapse. 

As  soon  as  the  patient  has  suflBciently  regained  her  health,  and 
other  circumstances  will  admit  of  it,  the  lacerated  perineum,  if  a 
laceration  has  existed,  should  be  closed,  and,  if  necessary,  the  ope- 
rations on  the  vaginal  walls  should  be  performed  for  restoring  the 
canal  to  its  normal  size.  These  operations  should  be  done  afterwards, 
for  it  is  not  good  practice  to  attempt  to  operate  on  the  lacerated 
cen'ix  and  at  the  same  sitting  close  the  perineum.  After  the  patient 
recovers  from  the  latter  operation,  the  question  will  arise  as  to  the 
necessity  for  some  modification  in  the   size  and  shape  of  the  pessary 


LACERATIONS  OF  THE  CERVIX  UTERI. 


477 


which  had  been  previously  woiti,  or  as  to  the  propriety  of  discon- 
tinuing its  use.  As  a  rule,  there  will  be  no  need  for  any  local  treat- 
ment afterwards  if  she  has  undergone  the  proper  preparation  for 
the  operation.  Then  with  the  improvement  in  the  general  condition 
all  discharge  will  cease,  and  the  uterus  will  gradually  regain  its 
normal  size. 

A  condition  is  sometimes  found  after  the  operation  for  which  I  can- 
not yet  offer  a  satisfactory  explanation.  Fig.  90  represents  a  double 
laceration,  and  at  C  is  shown  what,  in 
consequence  of  the  distance  to  which 
the  laceration  seems  to  have  extended 
(from  A  and  B^,  is  supposed  to  be 
the  internal  os.  We  will  suppose  an 
ordinary  case  as  to  relative  measure- 
ments, and  that  the  depth  of  the 
uterine  canal  from  C  is  three  and  a 
half  inches,  while  the  length  of  each 
flap  is  (from  C  to  A  and  B^  an  inch 
and  a  half  more.  Now,  Avere  we  to 
denude  these  flaps  and  bring  the  sur- 
faces together  with  sutures,  the  natu- 
ral inference  would  be  that  they  must 
occupy  the  space  included  by  the  dotted 
line  B,  and  the  depth  of  the  canal  would  then  be  five  inches.  Such, 
however,  is  not  the  case,  for  although  we  may  unite  these  flaps,  and 
apparently  add  an  inch  and  a  half  to  the  depth  of  the  canal,  there 
will  be  but  little  increase  from  what  it  was  before  the  operation.  In 
other  words,  when  the  flaps  A  and  B  have  been  united,  they  will 
come  together  at  C  instead  of  at  B,  with  but  little  increase,  and  some- 
times with  even  a  slight  decrease  in  the  length  of  the  canal  after  the 
operation. 

The  only  explanation  I  can  offer  is  based  on  the  supposition  that 
the  laceration  is  limited  to  the  cervix  and  does  not  reach  the  body; 
that  it  involves  chiefly  the  vaginal  wall,  and  is  never  so  extensive  as 
seems  apparent  to  the  eye.  When  we  see  a  laceration  through  the 
cervix  apparently  extending  upward  into  the  uterus  for  an  inch  and 
a  half,  it  is  probable  that  two-thirds  of  the  length  of  the  tear  is  in 
reality  on  the  vaginal  wall.  As  the  enlarged  uterus  prolapses  in  the 
canal  after  the  injury,  it  of  course  carries  with  it  a  reflection  of  the 
vaginal  walls  like  a  stocking  which  becomes  doubled  on  itself.  There- 
fore, when  A  is  supposed  to  be  drawn  to  C,  this  doubling  up  of  the 


Effect  of  laceration  involviu^'  the  vaginal 
■wall. 


478  DIAGNOSIS    AND    TREATMENT    OF 

tissues  is  pulled  out,  and  A  will  then  occupy  about  the  position  of  U 
on  the  vaginal  wall.  If  this  be  true  the  cervical  flap  does  not  extend 
to  A,  and,  in  all  probability,  not  beyond  the  dotted  line  at  F.  We 
may  then  suppose  that  the  diiference  is  due  to  the  fact  that  the  vaginal 
tissue  covering  the  circumference  of  the  cervix  has  become  thickened 
in  consequence  of  the  laceration.  When  the  sides  of  the  laceration 
through  the  cervix  are  brought  together,  the  efiect  is  to  draw  out,  as 
it  were,  the  neck  from  this  surrounding,  and  the  vaginal  tissue  looks 
as  if  it  had  retracted  suflSciently  to  leave  the  cervix  exposed.  If  this 
is  the  explanation,  there  can  be  comparatively  little  gaping  of  the  cer- 
vix itself;  yet  there  is  quite  enough  to  cause  much  disturbance,  but 
not  so  much  as  would  be  were  the  injury  to  the  uterus  greater.  The 
rent  through  the  neck  of  the  uterus  is  in  reality  a  small  portion  of 
what  seems  to  be  the  depth  of  the  fissure,  and  to  this  we  may  attribute 
the  little  change  found  in  the  length  of  the  canal  after  the  operation. 
It  is  evident  that  when  these  flaps  are  united  the  excess  of  tissue  is 
stripped  back  from  the  cervix,  and  the  line  of  union  is  then  chiefly  in 
the  vaginal  wall. 

It  will  frequently  happen,  with  an  extensive  laceration,  that  the 
tissue  forming  the  top  of  the  fissure  at  the  vaginal  surface,  and 
nearest  to  the  observer,  Avill  be  the  most  distant  when  the  sutures 
have  been  secured.  This  can  be  explained  by  the  diagram.  Fig,  91. 
We  will  suppose  A  B  C  to  represent  a  recent  fissure  through  the 


Diagram  of  laceration  involving  the  vagina. 

cervix,  terminating  in  the  uterine  canal  at  a'.  C  is  the  vaginal  edge 
of  the  fissure,  and  B  forms  the  angle  nearest  to  the  vaginal  outlet. 
It  is  held  that  the  curved  line  A  a'  is  the  extent  of  the  laceration  in 
the  cervix,  while  A  B  Q  i?,  vaginal  tissue  in  front  of  it.  But  when 
the  sutures  are  closed,  the  vaginal  tissue  becomes  crowded  back,  and 
the  point  tI  advances  to  D,  while  B  remains  stationary,  so  that  the 
curved  line  d'  i),  the  limit  of  the  true  laceration,  and  which  as  a'  A 
was  previously  at  the  bottom  of  the  fissure,  is  now  in  front.  Before 
the  change,  the  line  of  laceration  A  B  extended  into  the  vaginal  tissue 
which  then  covered  the  cervix.     But  now,  when  the  change  from  A 


LACERATIONS  OF  THE  CERVIX  UTERI.         479 

to  D  is  made,  the  line  i)  B  becomes  in  fact  part  of  the  vaginal  wall. 
It  lies  against  the  side  of  the  uterus,  but  since  it  is  drawn  out  it  is  now 
but  a  superficial  continuation  of  the  line  of  laceration,  without  depth 
yet  apparently  as  extensive  as  before. 

It  is  not  unreasonable  to  suppose,  in  consequence  of  the  continued 
irritation  dependent  on  the  laceration,  that  a  condition  of  congestion 
is  kept  up  in  this  erectile  tissue,  and  may  be  termed  an  erection  of 
the  uterus.  In  consec^uence  of  the  loss  of  blood  at  the  time  of  the 
operation,  and  of  the  subsequent  removal  of  the  source  of  irritation, 
this  state  of  erection  will  gradually  cease,  so  that  the  uterine  canal 
may  shorten  from  an  inch  to  an  inch  and  a  half  in  the  course  of  ten 
days,  as  I  have  frequently  observed. 

As  soon  as  the  practitioner  becomes  able  to  recognize  this  lesion 
under  its  different  forms,  he  will  be  surprised  to  find  a  new  explana- 
tion of  all  his  cases  of  elongated  or  hypertrophied  cervix,  as  well  as 
those  of  ulceration.  Let  him  in  all  such  cases  simply  make  the 
attempt,  with  a  tenaculum  in  each  hand,  to  bring  the  points  A  and 
B  (Fig.  90)  together  at  C\  and  a  revelation  will  be  opened  to  him.  It 
will  be  necessary  to  employ  Sims's  speculum,  or  some  instrument  of 
the  same  kind,  for  otherwise  the  condition  will  not  be  detected.  This 
I  believe  to  be  difiicult  with  any  valvular  or  cylindrical  instrument,  for 
these  put  the  parts  on  the  stretch.  To  this  fact  is  doubtless  due  the 
difference  of  opinion  which  exists  to-day  as  to  the  frequency  of  this 
injury.  But  let  any  one  once  master  the  diagnosis,  and  he  will  not 
fail  to  recognize  the  protean  nature  of  lacerations,  and  will  never  see 
another  case  of  hypertrophied  cervix,  or  a  so-called  elongated  neck. 
Moreover,  he  wdll  never  have  occasion  afterwards  to  amputate  the 
cervix,  or  any  portion  of  it,  except  for  malignant  disease.  This  has 
been  my  experience  during  the  past  nine  or  ten  years,  and  in  so  laro-e 
a  practice  that,  if  hypertrophy  and  elongation  existed  in  reality,  I 
could  not  have  failed  to  recognize  them.  What  observer  has  ever 
met  with  either  of  these  conditions,  except  after  childbirth  or  an 
abortion?  Why  may  they  not  then  be  due  to  laceration  ?  I  will,  no 
doubt,  be  reminded  of  certain  cases  of  supposed  elongation  of  the 
cervix  found  in  unmarried  women,  but  I  deny  that  such  a  lesion  exists, 
as  will  be  shown  hereafter. 

From  my  standpoint,  therefore,  I  can  but  denounce  an  amputation, 
with  scissors,  knife,  or  cautery,  of  a  so-called  hypertrophy  or  an 
elongation  of  the  cervix  as  malpractice.  I  also  deprecate,  as  even 
more  uncalled  for,  the  application  of  the  cautery  or  caustics  to  heal 
a  so-called  ulceration  on  surfaces  which  can  be  readily  united  and 


480      DIAGNOSIS    AND    TREATMENT    OP    LACERATIONS,    ETC. 

brought  into  a  healthy  condition.  Nothing  is  proved  by  the  state- 
ment that  a  certain  number  of  Avomen  have  recovered  their  health 
after  the  cervix,  or  a  portion  of  it,  has  been  removed,  for  I  have 
seen  many  after  my  own  work  in  this  line  do  so.  A  man  may 
doubtless  enjoy  good  health  after  the  head  of  the  penis  has  been 
removed,  even  if  it  were  done  with  the  cautery,  yet,  if  the  ope- 
ration is  unnecessary,  it  would  be  malpractice  to  perform  it.  The 
rule,  however,  is  not  for  permanent  benefit  to  result,  for  no  woman 
can  remain  in  continued  good  health  so  long  as  an  extent  of  cicatricial 
tissue  exists  in  the  vagina,  for  both  her  nervous  system  and  her 
nutrition  will  suffer  from  it.  Amputation  of  the  cervix,  or  the  repeated 
application  to  it  of  cautery  or  caustics,  will  maim  any  woman,  and 
most  likely  render  her  sterile ;  and  for  the  want  of  the  support  which 
the  cervix  normally  affords,  she  will  be  liable  to  suffer  from  displace- 
ment of  the  uterus.  If  this  so-called  hypertrophy,  or  this  elongated 
cervix,  should  prove  to  be  simply  a  laceration,  the  sides  of  which  can 
be  brought  together  and  united,  so  that  the  integrity  of  the  parts  will 
be  as  perfect  as  if  the  accident  had  never  occurred,  then  to  resort  to 
ablation  or  cauterization  is  malpractice. 

To  those  who  are  familiar  with  this  subject  it  will  not  seem  as  if  it 
had  been  treated  of  to  an  extent  beyond  its  merits.  Its  importance 
cannot  be  exaggerated,  since  at  least  one-half  of  the  ailments  among 
those  who  have  borne  children  are  to  be  attributed  to  lacerations  of 
the  cervix. 


AMPUTATION    OF    THE    CERVIX.  481 


CHAPTER  XXV. 

AMPUTATION  OF  THE  CERVIX  UTERI. 

Never  called  for  except  for  malignant  disease — True  elongation  of  the  cervix  does 
not  exist — Double  laceration  often  mistaken  for  elongation — What  is  the  true 
condiiion  ? — Treatment  by  the  cautery — Intra-uterine  stem  pessary — Mode  of 
amputating — Cicatricial  cervix. 

I  ENTER  upon  a  consideration  of  this  operation  immediately  after 
treating  of  laceration  of  the  cervix,  not  because  there  is  any  connec- 
tion between  the  tAvo,  but  because  I  desire  by  the  juxtaposition  to 
make  more  emphatic  my  condemnation  of  amputation  as  a  remedy  for 
laceration  in  any  of  its  forms. 

I  adv^ance  the  statement,  without  qualification,  that  this  operation, 
as  at  present  applied,  is  to  a  greater  extent  a  malpractice,  and  is  at- 
tended by  more  evil  consequences  than  any  other  procedure  now 
resorted  to  in  this  branch  of  surgery.  In  fact,  I  am  satisfied  from 
experience  that  removal  of  the  cervix  is  never  called  for  except  in 
some  forms  of  malignant  disease.  The  operation  is,  I  grant,  still  held 
by  the  profession  to  be  a  legitimate  one,  but  its  supposed  necessity 
is  based  upon  false  pathology.  The  commonest  error  of  the  day  is  a 
mistake  in  diagnosis  between  a  laceration  of  the  cervix  and  its  sup- 
posed enlargement  or  elongation.  I  have  not  amputated  a  cervix  in 
some  nine  years  for  any  other  condition  than  that  of  malignant 
disease  ;  nor  seen  in  the  same  space  of  time  a  single  instance  of  hyper- 
trophied  or  so-called  elongated  cervix,  which  was  not  due  to  laceration 
of  the  uterine  os  and  neck.  Since  amputation  of  the  cervix  Avas  for 
years  an  operation  frequently  performed  by  me  for  the  relief  of  those 
supposed  conditions  which  I  now  no  longer  find,  but  which  I  recognize 
and  cure  as  lacerations,  the  inference  is  a  natural  one  that  formerly 
I  was  in  error.  I  confess  that  this  was  true,  and  it  is  equally  true 
to-day  that  the  profession  all  over  the  Avorld  are  cutting  off  and  burn- 
ing off  parts  of  ihe  cervix  which,  if  otherwise  properly  treated,  Avould 
result  in  restoring  the  uterus  to  its  normal  condition.  I  am  not  an 
enthusiast,  I  have  not  deceived  myself,  nor  do  I  exaggerate  these 
statements  in  the  slightest  degree.  Yet  their  truthfulness  will  be 
questioned,  I  have  no  doubt,  by  two  classes,  equally  coascientious  in 
31 


482  AMPUTATION    OF    THE    CERVIX    UTERI. 

their  position,  viz.,  those  who  are  too  indolent  to  thoroughly  investi- 
gate the  merits  of  the  case,  and  those  who  remain  in  ignorance  from 
having  already  reached  an  age  (varying  with  all  of  us)  at  which  we 
cease  to  appreciate  new  ideas.  But  let  the  reader  carefully  study 
the  description,  already  given,  of  lacerations  of  the  cervix,  and,  in 
any  case  of  doubtful  diagnosis  met  with  in  practice,  let  him  make  the 
attempt  to  bring  opposite  surfaces  of  the  uterine  lips  together,  and 
he  will  be  surprised  at  the  result.  Whenever  he  fails  to  demonstrate 
that  the  parts  have  been  lacerated,  it  will  be  the  exception  to  the 
rule,  unless,  indeed,  the  fault  rests  with  himself  in  his  want  of  the 
necessary  knowledge. 

It  is  true  that  occasionally,  after  a  laceration,  the  parts  become 
hardened,  thickened,  or  elongated,  and  cannot  always  be  adjusted 
with  any  degree  of  accuracy.  Nevertheless  the  true  condition  may 
be  recognized,  and  the  parts  properly  treated  until  they  can  be  brought 
together  in  a  more  healthy  state.  I  grant  that  cases  of  hypertrophy 
of  the  cervix  are  frequently  met  with,  and  cases  of  apparent  enlarge- 
ment resulting  from  a  reduplication  of  the  vaginal  wall  covering  a 
prolapse,  but  amputation  is  not  the  remedy  for  these.  I  am  almost 
prepared  to  deny  that  such  a  condition  as  elongation  of  the  whole 
cervix  ever  exists  ;  it  certainly  is  never  found  in  a  woman  who  has 
ever  been  impregnated.  Sometimes  when  lateral  laceration  has 
occurred,  the  anterior  lip  becomes  apparently  elongated,  and  even  this, 
as  a  rule,  is  a  deception:  the  posterior  flap  becomes  caught  on  the 
posterior  vaginal  wall,  while  the  anterior  one  is  crowded  forward  in 
the  axis  of  the  vagina.  This  will  cause  the  parts  to  roll  out  more 
extensively,  and  the  excess  of  tissue  becomes  crowded  on  to  the  ante- 
rior flap.  When  such  a  case  is  examined  on  the  knees  and  elbows, 
the  apparent  enlargement  disappears,  and  it  becomes  evident  that 
the  true  condition  is  one  of  laceration.  Since  I  deny  that  under  any 
circumstances  amputation  would  be  justifiable,  or  ought  ever  to  be 
employed  for  the  relief  of  this  condition,  it  will  be  unnecessary  for 
me  to  enter  into  a  consideration  of  the  evil  consequences  attending 
the  practice. 

Among  the  sterile  and  unmarried  women  cases  occasionally  come 
under  observation  which  are  supposed  to  be  instances  of  elongated 
cervix,  Avhen  the  disease  is  not  in  the  cervix  proper,  and  instead  of 
there  being  an  enlargement  of  this  portion,  actually  atrophy  is  the 
rule.  Some  change  in  the  character  of  the  tissues  forming  the  supra- 
vaginal portion  of  the  uterus  takes  place,  of  the  precise  ciiaracter  of 
which  I  must  confess  my  ignorance.     It  is  to  be  hoped  that  at  some 


ELOJiGATED  CERVIX.  483 

early  date  the  pathologist  may  be  able  to  throw  sufficient  light  on  the 
subject  to  indicate  the  proper  mode  of  treatment.  In  such  a  case  the 
uterine  body  becomes  elongated  when  the  woman  stands,  and  while  the 
fundus  remains  stationary  the  tissues  below  stretch  out,  as  if  formed 
of  soft  putty,  becoming  elongated  by  their  own  weight.  In  this 
prolapse  the  uterine  neck  is  pushed  forward  in  the  vagina,  and  fre- 
quently beyond  the  outlet,  and  the  supra-vaginal  portion  of  the  uterus 
appears  with  a  covering  of  the  vagina,  presenting  the  appearance  of 
an  elongated  cervix.  The  probe  may  be  passed  in  such  a  case  five 
or  six  inches,  or  a  large  blunt  sound  can  be  introduced  to  the  fundus, 
"when,  if  the  cervix  be  drawn  down  with  a  tenaculum,  along  the  staff 
to  the  handle,  the  depth  of  the  canal  is  shown  to  be  eight  or  nine 
inches.  If  the  finger  be  introduced  in  the  rectum,  the  body  of  the 
uterus  will  be  felt  much  attenuated,  and  when  the  cervix  ii  drawn 
down  to  the  full  length  of  the  sound,  the  instrument  seems  to  have 
little  more  than  a  membrane  covering  it.  If  we  next  place  such  a 
patient  on  the  knees  and  elbows  for  examination,  the  change  brought 
about  will  be  a  remarkable  one.  The  whole  of  this  elongation  will 
disappear,  and  the  uterus  will  be  found  but  two  and  a  half  inches  in 
depth.  The  cervix  itself,  as  a  rule,  is  atrophied,  as  the  result  of  the 
continued  traction  made  by  the  vaginal  tissues  during  the  prolapse. 
In  this  position  the  uterus  seems  to  shut  up,  falling  together  as  would 
an  old  worn-out  spy  glass  if  held  upright. 

The  fundus  of  the  uterus  seldom  becomes  involved  in  this  prolapse, 
nor  is  traction  exerted  on  the  peritoneum  at  any  point.  The  disease 
is  evidently  confined  to  a  space  of  scarcely  more  than  an  inch  from  the 
vaginal  junction.  As  the  prolapse  occurs  the  surrounding  cellular,  or 
connective,  tissue  is  carried  with  it  and  is  equally  stretched.  This  is 
the  explanation  of  the  fact  that  the  bladder  and  peritoneal  cavity  are 
rarely  entered  when  a  supposed  elongated  cervix  has  been  amputated. 
The  line  of  separation  is  below  the  vaginal  junction,  and  the  cellular 
tissue  above,  in  connection  with  the  peritoneum,  is  a  protection, 
while  the  peritoneum  itself  often  escapes  injury  in  consequence  of  its 
distance. 

I  am  inclined  to  believe  that  an  error  of  diagnosis  has  been  made 
whenever  the  peritoneal  cavity  or  bladder  becomes  involved  in  the 
operation  of  amputation  of  the  cervix.  In  every  instance,  when  the 
accident  has  occurred  within  my  knowledge,  the  woman  had  borne 
children,  and  I,  therefore,  drew  the  inference  that  there  had  been  no 
elongation,  but  a  double  laceration  of  the  cervix. 

Of  these  cases  of  prolapse,  due  to  this  elastic  condition  above  the 


484  AMPUTATION    OF    THE    CERVIX    UTERI. 

vaginal  junction,  I  have  met  with  two  instances  where  permanent 
benefit  seemed  to  have  followed  the  removal  of  a  portion  of  the  neck. 
On  the  other  hand,  I  have  had  five  cases  which  were  not  benefited,  but, 
on  the  contrary,  made  much  worse.  I  feel,  therefore,  that  we  may 
question  Avhether  the  advantage  gained  is  ever  more  than  a  temporary 
one.  It  may  be  stated  that  of  these  cases  five  only  remained  for 
any  length  of  time  under  observation.  The  others  Avere  apparently 
relieved,  temporarily  at  least,  but  they  may  have  passed  into  the 
hands  of  others.  It  may  be  claimed  that  my  failure  was  due  to  the 
comparatively  insignificant  amount  of  tissue  removed  by  me.  This, 
however,  is  not  the  case  ;  moreover,  my  views  Avere  formed  from  a 
knowledge  of  the  results  obtained  by  others  before  my  first  operation. 
In  addition  to  these  five  cases  of  my  own,  I  have  had  under  my  care 
at  the  Woman's  Hospital  fifteen  or  twenty  cases  in  which  the  cervix 
had  been  amputated  by  others.  In  all  of  these  the  full  length  of 
what  was  supposed  to  be  the  cervix  had  been  removed.  In  some  of 
these  cases  the  prolapse  bad  been  cured  by  the  removal  of  a  large 
portion  of  the  diseased  tissue,  and  by  the  subsequent  contraction. 
But  in  all,  the  iiterus  had  become  again  enlarged,  in  all  probability 
more  so  than  before,  and  from  the  loss  of  the  uterine  neck  it  was  im- 
possible to  keep  the  uterus  from  falling  about  the  pelvis  in  every 
direction. 

Yet  under  certain  circumstances,  as  shall  be  shoAvn,  a  partial 
amputation  of  the  cervix  may  be  performed.  But  I  hold  that  the 
removal  of  any  portion  of  the  uterine  neck  is  uncalled  for,  except  as 
stated  above,  and  for  the  removal  of  malignant  disease.  This  has  led 
me  to  consider  the  operation  more  in  its  relation  to  this  lesion  of  the 
body  of  the  uterus,  than  as  a  special  procedure  in  uterine  surgery. 
Having,  however,  gone  thus  far,  it  Avould  lead  to  confusion  and  some 
repetition  hereafter  to  omit  all  reference  to  the  modes  of  treatment  to 
be  resorted  to  in  those  conditions  for  which  hitherto  amputation  of  the 
cervix  has  been  employed. 

The  portion  removed  in  the  usual  operation,  although  unnecessarily 
large,  is  of  itself  too  small  and  of  too  little  Aveight  to  afford  mechani- 
cal relief  to  the  prolapse.  The  chief  benefit,  if  any,  derived  from  the 
operation  is,  I  believe,  due  to  the  revulsive  effect,  and  possibly  to  a 
limited  cellulitis,  Avhich  may  be  set  up  around  the  diseased  portion.  I 
would  therefore  recommend  that  amputation  be  employed  as  a  last 
resort  after  other  means  have  been  fairly  tested. 

I  have  observed  good  results  follow  the  frequent  use  of  sponge  tents 
to  dilate  the  Avhole  canal.     After  their  removal  I  am  accustomed  to 


SUBSTITUTES    FOR    AMPUTATION.  485 

inject  a  quantity  of  liot  water  into  the  uterine  canal,  and  then  to 
apply  iodine  freely. 

Some  means  should  also  be  employed  to  prevent  the  recurrence  of 
the  prolapse,  and  for  keeping  the  parts  continually  in  close  contact  for 
a  length  of  time.  After  treating  the  case  in  the  above  manner  the 
patient  may  be  placed  on  the  knees  and  elbows  for  the  purpose  of 
introducing  a  little  cotton,  saturated  with  glycerine,  as  a  temporary 
means  of  preventing  the  prolapse.  An  inflated  India-rubber  disk,  as 
described  for  use  in  lacerations  of  the  cervix,  may  be  temporarily 
employed,  but  not  if  it  can  be  avoided,  since  by  long  use,  it  must 
necessarily  dilate  the  vagina,  and  so  as  to  add  to  the  difficulty.  A 
permanent  pessary  is  best  made  of  hard  rubber,  well  fitted  to  the  size 
of  the  vagina,  but  with  less  curve  for  the  posterior  cul-de-sac  than 
Avould  be  otherwise  applicable.  A  light  cup  of  rubber  must  be  used 
to  contain  the  cervix,  and  this  is  to  be  swung  at  the  proper  point 
between  the  sides  of  the  pessary,  by  a  pivot  on  each  side.  The 
perfect  fitting  of  this  instrument  will  prevent  any  prolapse  of  the 
neck,  and  at  the  same  time  keep  the  uterus  anteverted  whenever  the 
patient  is  on  her  feet. 

I  have  seen  benefit,  I  am  sure,  from  the  application  of  a  blister  on 
the  cervix  after  each  period.  Until  this  has  healed,  which  requires 
some  five  or  six  days,  the  patient  must  remain  in  bed.  She  should 
employ  the  bed-pan,  and  not  assume  the  upright  position  until  the 
cessation  of  the  discharge,  and  the  pessary  has  been  again  adjusted. 

The  plan  of  employing  the  cautery  has  suggested  itself,  but  I  have 
never  put  the  treatment  into  practice,  and  am  quite  sure  my  opposition 
is  founded  on  correct  principles,  since  the  chief  effect  of  the  cautery  is 
to  bring  about  a  condensation  of  tissue,  a  result  which  we  know  is 
very  objectionable  under  almost  all  circumstances. 

After  the  uterus  has  been  fully  dilated  and  shortened  from  placing 
the  patient  on  the  knees  and  elbows,  it  has  occurred  to  me  that  much 
advantage  would  be  derived  from  making  four  lineal  applications,  of  a 
properly  shaped  cautery,  along  the  sides  of  the  canal  to  within  a  short 
distance  of  the  os,  from  which,  if  the  os  be  properly  protected,  no  seri- 
ous consequence  will  be  likely  to  result.  This  treatment  would  estab- 
lish a  powerful  revulsive  effect,  and  act  mechanically,  just  as  it  does 
when  applied  to  a  prolapse  of  the  rectal  tissue.  The  presence  of 
these  cicatrices  would  produce  no  irritation  through  the  medium  of  the 
sympathetic,  since  they  would  not  be  made  in  pure  erectile  tissue,  nor 
would  contraction  of  the  canal  be  likely  to  occur  unless  the  os  uteri 
had  been  also  involved.     The  selection  of  this  method  would  be  only  a 


486 


AMPUTATION  OF  THE  CERVIX  UTERI. 


Fis.  92. 


choice  of  evils,  yet  it  could  never  produce  the  bad  consequences  which 
frequently  follow  amputation  with  the  galvanic  wire  or  the  ^craseur. 

Whatever  information  may  be  gained  by  future  investigation,  as  to 
the  pathological  cause  of  this  singular  lesion,  experience  certainly 
teaches  the  necessity  for  correcting  the  prolapse,  and  for  carefully 
guarding  against  its  recurrence  for  an  indefinite  period.  For  this 
purpose,  I  believe  that  a  self-retaining  intra-uterine 
stem  may  prove  useful.  It  may  be  formed  of  two 
portions  of  steel,  which  have  been  tempered,  Avith  a 
curve  in  opposite  directions.  The  two  lower  ends  are  to 
be  joined  together  below  and  secured  by  screwing  into 
a  light  cap.  The  upper  ends  should  be  protected  by  a 
terminal  bulb  for  each.  Over  the  two  springs  should 
slide  a  cylindrical  stem,  which  would  bring  the  two 
bulbed  extremities  together  for  their  inti-oduction,  but 
when  drawn  towards  the  cup  would  allow  them  to  sepa- 
rate, each  one  to  occupy  a  horn  of  the  uterus  (see 
Fig.  92).  By  this  means  the  instrument  would  be 
self-retaining,  and  the  cup  attached  below  would  pre- 
vent the  prolapse  of  the  cervix.  The  spring  should 
only  be  of  a  sufficient  strength  to  retain  the  instrument, 
but  under  any  circumstances  it  would  be  difficult  to 
30  regulate  this  that  it  would  not  prove  a  source  of  irri- 
tation. In  finishing  the  instrument,  great  care  must  be  taken  to  round 
off  the  edges,  and  especially  the  upper  part  of  the  cylinder.  The  stem 
portion  should  be  made  a  little  over  two  inches  and  a  half  in  length,  if 
the  uterus  shortens  to  that  depth  when  the  woman  is  on  the  knees  and 
elbows.  It  will  be  necessary  to  nickel-plate  the  steel  portions  of  the 
instrument  to  protect  them  from  the  action  of  the  secretions.  I  have 
for  some  time  determined  to  try  this  plan  of  treatment  on  the  first 
case  coming  under  my  observation,  but  it  has  so  happened  I  have  not 
met  with  a  well-marked  instance  in  several  years.  The  presence  of  a 
foreign  body  in  the  canal  may  of  itself  prove  of  service  in  bringing 
about  an  alterative  action,  and  the  danger  which  always  exists  in  using 
stem  pessaries  in  flexures  of  the  uterus  would  be  absent  here. 

Since  this  condition  may  be  regarded  as  one  of  atrophy  (most 
likely  of  muscular  fibre),  the  stimulus  to  be  derived  from  the  use  of 
electricity  may  prove  serviceable  in  causing  a  development  of  new 
tissue.  x\s  a  continued  local  stimulant,  for  the  same  purpose,  the 
galvanic  current,  established  by  the  action  of  the  secretions  on  plates 
of  zinc  and  copper,  might  be  applied,  as  has  been  used  in  the  form  of 


Self-retaining  in- 
tra-uterine stem. 


EVIL    EFFECTS    OF    AMPUTATION.  487 

an  inter-uterine  stem  to  stimulate  the  growth  of  an  undeveloped  uterus. 
The  disk  of  this  stem  may  be  attached  by  pivots  to  the  sides  of  the 
pessary  in  the  same  manner  as  the  cup,  or  it  may  rest  in  it.  These 
suggestions  are  made  from  realizing  the  great  difficulty  sometimes 
experienced  in  fitting  a  pessary.  The  vagina  is  often  very  short, 
without  a  posterior  cul-de-sac,  and  the  whole  passage  remains  in  an 
irritable  condition.  But  whenever  a  pessary  can  be  adjusted,  it  then 
becomes  an  easy  matter  to  attach  the  cup,  and  thus  prevent  the  pro- 
lapse of  the  cervix  for  an  indefinite  period. 

After  every  reasonable  procedure  has  been  resorted  to,  and  with- 
out benefit,  a  portion  of  the  cervix  may  then  be  removed  as  a  last 
resort,  and  as  an  experiment.  Let  the  operation  be  done  with  scissors 
and  in  the  manner  to  be  hereafter  described,  but  never  Avith  the  gal- 
vanic Avire  or  the  ^craseur.  I  most  strenuously  object  to  these  instru- 
ments on  account  of  the  cicatricial  tissue  i-esulting  from  their  use,  and 
in  consequence  of  the  certainty  of  partial  or  complete  obstruction  to 
the  outlet,  from  subsequent  contraction.  Neither  of  these  instruments 
divides  the  tissues  directly  across,  they  both  draw  out  the  mucous 
membrane  and  submucous  tissue  at  some  depth  from  the  uterine  canal. 
The  subsequent  eifect  is  in  some  degree  similar  to  Huguier's  operation 
in  which  the  tissues  are  excavated  or  removed  in  a  cone  shape — a 
most  reliable  procedure  for  obliterating  in  time  even  the  semblance  of 
an  OS. 

For  instance,  after  the  cervix  has  been  removed  in  the  usual 
manner  for  hypertrophy  or  induration,  and  left  to  heal  by  granula- 
tion, a  very  remarkable  improvement  at  first  takes  place,  unless  an 
attack  of  cellulitis  should  have  been  excited.  The  uterus  rapidly 
decreases  in  size,  the  tissues  become  as  soft  as  in  a  healthy  state,  and 
this  improvement  will  last  sometimes  for  one  or  two  years.  But 
gradually  the  cicatricial  tissue  contracts  and  becomes  more  dense, 
until  at  length  this  condition  exercises  a  most  deleterious  influence  on 
nutrition  through  reflex  agencies.  The  uterus  begins  to  increase  in 
size,  and  finally  becomes  even  larger  than  before.  Either  the  mouth 
of  the  uterine  canal  contracts,  partially,  so  as  to  cause  great  men- 
strual disturbance,  or  the  flow  becomes  retained.  There  are  members 
of  the  profession,  for  whose  opinion  I  have  the  highest  respect,  ready 
on  all  occasions  to  deny  that  these  results  are  common,  or  are  even 
to  be  met  with.  But  I  know  of  no  one  who  has  had  better  oppor- 
tunity than  myself  for  keeping  these  ca?es  under  observation.  I 
have  had  some  of  these  women,  who  have  been  operated  on,  to  visit 
me  at  a  regular  interval  for  years,  that  I  might  study  these  changes. 


488 


AMPUTATION    OF    THE    CERVIX    UTERI. 


From  observation,  I  do  not  hesitate  to  affirm  that  it  is  only  as  a  rare 
exception  to  the  rule  that  these  evil  consequences  do  not  follow  every 
amputation  of  the  entire  cervix,  and  especially  so  whenever  the  sur- 
face has  been  left  to  heal  by  granulation. 

Amputation  of  the  uterine  neck  was  an  operation  which  had  been 
long  practised  by  French  surgeons,  but  Huguier  at  quite  a  recent 
date  has  brought  the  operation  into  greater  prominence.  The  cervix 
has  been  removed,  according  to  the  fancy  of  the  operator,  with  the 
knife,  dcraseur,  or  by  the  galvanic  cautery,  for  supposed  elongation, 
and  for  the  relief  of  procidentia.  But  under  all  circumstances  the 
stump  has  been  usually  left  to  heal  by  granulation,  a  process  which 
requires  from  four  to  six  weeks. 

During  the  autumn  of  1859,  Dr.  Sims  made  a  most  valuable  con- 
tribution to  the  surgery  of  the  cervix  by  covering  the  stump  with 
vaginal  tissue.  In  this  Avay  he  obtained  union  by  the  first  intention, 
and  in  my  estimation  an  incalculable  benefit  was  secured  by  thus  pre- 
venting the  formation  of  cicatricial  tissue.     In  Fig.  93,  A  represents 


Fig.  93. 


stump  after  amputation  of  the  cervix. 


Flaps  secured  by  sutures. 


the  stump  from  which  the  cervix  has  been  amputated  just  at  the  vagi- 
nal junction.  The  sutures  have  been  introduced  so  as  to  take  up  a 
sufficient  amount  of  vaginal  tissue  along  the  edge,  but  not  to  include 
any  portion  of  the  cervix.  When  these  sutures  are  secured,  as  shown 
in  the  same  figure  at  B,  the  vaginal  tissue  Avill  be  drawn  without 
difficulty  over  the  stump  in  a  manner  similar  to  that  in  which  the  soft 
parts  are  brought  together  in  a  circular  amputation  of  the  arm  or  leg. 
Whenever  the  neck  has  been  removed  Avith  a  clean  cut,  by  the  knife 
or  scissors,  and  the  stump  covered,  there  can  scarcely  be  any  undue 
contraction  of  the  uterine  canal  afterwards,  since  the  tissues  can  only 


CICATRICIAL    CERVIX.  489 

heal  up  to  and  around  the  edge,  thus  leaving  the  canal  of  the  same 
diameter  as  before  the  operation. 

It  has  been  already  stated  that  I  do  not  advocate  the  entire  removal 
of  the  cervix  under  any  circumstances  except  for  malignant  disease. 
As  the  members  of  the  profession  become  more  expert  in  recognizing 
the  different  conditions  resulting  from  laceration  of  the  cervix,  the 
operation  will  become  confined  more  and  more  to  the  limit  I  have 
indicated. 

We  may  occasionally  meet  an  instance  of  a  class  of  cases  quite 
common  some  years  ago,  in  which  the  cervix  is  found  enlarged,  every 
raucous  follicle  destroyed,  and  the  tissues  white  and  as  dense  as  an 
ivory  billiard-ball,  owing  to  the  long  use  of  the  nitrate  of  silver,  or  the 
actual  cautery.  These  cases  would  be  apparently  legitimate  ones  for 
amputation,  if  the  procedure  should  be  employed  for  any  class  not 
malignant,  and  yet  even  with  these  the  operation  is  unnecessar}'.  I 
have  invariably  obtained  in  such  cases  everj  advantage,  without  the 
disadvantages,  of  amputation,  by  simply  removing,  in  the  most  super- 
ficial manner,  with  a  pair  of  scissors,  what  was  the  mucous  and  sub- 
mucous tissue,  and  then  covering  the  denuded  surface  with  the  vaginal 
tissue  as  practised  by  Dr.  Sims.  As  Ave  thus  remove  the  source  of 
irritation,  which  was  the  cicatricial  or  dense  tissue,  we  will  obtain  as 
full  a  revulsive  efiect  as  if  the  entire  cervix  had  been  amputated.  We, 
moreover,  thus  transplant,  as  it  Avere,  a  new  set  of  mucous  follicles, 
bloodvessels,  and  absorbents,  which  will,  in  time,  bring  about  a  re- 
markable change  to  a  healthy  condition  of  the  deeper  tissues. 

The  lateral  tension,  Avhich  is  exerted  as  soon  as  the  sutures  have 
been  secured,  will  generally  be  sufficient  to  arrest  any  bleeding.  If, 
however,  oozing  should  continue,  a  very  moderate  sized  compress  in 
the  vao;ina  for  a  few  hours  Avill  ba  sufficient  to  control  it,  since  the 
tissues  in  contact  Avith  the  freshened  surface  adhere  very  rapidly. 
The  after-treatment  is  in  every  respect  similar  to  that  advised  for  the 
operation  of  uniting  the  lacerated  portion  of  a  cervix  uteri. 


490      CANCER  OF  UTERUS,  VAGINA,  RECTUM,  ETC. 


CHAPTER  XXYI. 

CANCER  OF  THE  UTERUS,  VAGINA,  RECTUM,  AND  EXTERNAL  ORGANS 

OF  GENERATION. 

Definition — Varieties — Etiology — Rare  among  Negroes — More  common  among  the 
richer  than  among  the  poorer  classes — Tables  XXXVIII.  and  XXXIX. — Epithe- 
lioma— Sarcoma — Corroding  ulcer — Cancer  of  external  organs  of  generation. 

Cancer  maybe  described  as  a  disease  of  which  the  first  manifesta- 
tion is  local,  but  which  tends  rapidly  to  involve  the  whole  system.  Its 
progress  is  marked  by  destruction  of  tissue,  and  death  results  from 
ursemic,  or  blood-poisoning,  or  from  the  effects  of  hemorrhage. 

The  beginning  of  this  malady  is  yet  unknown,  but  the  probability 
is  greatly  in  favor  of  the  supposition  that  it  is  due  to  perverted  nutri- 
tion, and  is,  therefore,  of  local  origin.  I  am  impressed  with  the  belief 
that  it  often  has  a  beginning  in  the  efforts  of  nature  to  repair  or  re- 
move the  consequences  of  an  injury.  New  growth  is  thus  stimulated, 
but  from  some  defect  or  loss  of  balance  the  process  is  not  properly 
checked  or  limited.  The  cells  so  rapidly  formed,  as  if  from  a  want 
of  vitality,  soon  undergo  disintegration,  and  are  collected  together  as 
cancer  matter.  So  far  the  condition  remains  purely  a  local  one.  But 
soon,  in  the  effort  to  preserve  the  balance  between  waste  and  repair, 
this  material  becomes  absorbed.  It  is  carried  to  a  distance  until  it 
becomes  arrested  in  the  lymphatic  glands,  beyond  which,  if  it  could 
pass,  it  might  be  eliminated  or  thrown  out  from  the  system.  This 
cancerous  material,  when  thus  arrested  in  the  lymphatics,  clogs  up 
the  channels,  and  so  destroys  the  function  of  the  gland.  Here  this 
foreign  body  may  lie  dormant  for  an  indefinite  period,  but  eventually 
it  will  break  down.  From  this  new  point  the  poison  is  carried  in 
different  directions,  and  the  disease  becomes  a  constitutional  one. 
This  stage  is  to  be  recognized  by  "  cancerous  cachexia,"  where,  coinci- 
dent with  loss  of  .blood  and  the  effects  of  blood-poisoning,  the  features 
become  pinched,  and  the  complexion  of  a  peculiar  sallow  or  straw 
color.  Yet  this  does  not  always  occur,  for  instances  are  occasionally 
met  with  where  this  condition  docs  not  appear  even  in  the  last  stages 
of  the  disease. 

Not  a  little  confusion  is  to  be  found  among  writers  as  to  the  terms 


VARIETIES.  491 

and  description  applicable  to  the  various  forms  of  cancer.  For  all 
practical  purposes  and  for  convenience  of  description  a  division  may 
be  made  into — 

Epithelial  cancer. 

Sarcoma. 

Corroding  ulcer. 

Epithelial  cancer  is  found  under  two  forms,  Epithelioma  and  Carci- 
noma. It  springs  from  the  raucous  membrane  on  the  cervix,  or  from 
the  canal  below  the  internal  os. 

Sarcoma  originates  in  the  connective  tissue  of  the  uterus ;  it  has  its 
seat  generally  near  the  fundus,  and  is  seldom,  if  ever,  found  below 
the  internal  os. 

Corroding  ulcer  has  its  beginning,  so  far  as  my  observation  extends, 
on  the  vaginal  surface  of  the  cervix,  and  while  it  may  involve  the 
uterus,  it  extends  chiefly  in  the  vagina  and  on  the  external  organs  of 
generation. 

Epithelioma  is  also  known  as  papilloma,  and  as  cauliflower  excres- 
cence. 

The  papilljB,  or  villous-like  projections  from  the  epithelial  surface 
of  the  mucous  membrane,  are  formed  by  the  expansion  of  the  ultimate 
twigs  and  loops  of  the  vessels  and  nerves. 

From  these  papillae  springs  this  disease,  in  its  first  growth.  They 
enlarge  by  the  rapid  increase  in  size  of  their  bloodvessels,  which  be- 
come looped  upon  themselves.  These  growths  continue  to  be  covered 
by  a  thickened  mucous  membrane,  until  they  begin  to  break  down  by 
ulceration.  They  are  club-shaped,  and  as  they  shoot  out  in  every 
direction  they  present  in  outline  the  appearance  of  a  cauliflower  gi'owth. 
Within  the  meshes  of  this  villous  tissue  may  now  be  found  new  cells 
of  all  sizes  and  shapes,  thus  indicating,  by  these  characteristics,  their 
rapid  growth. 

Carcinoma  begins  essentially  in  the  same  manner  on  the  epithelium 
of  the  uterine  canal,  but  spreads  in  the  opposite  direction  from  epithe- 
lioma, or  papilloma,  by  sinking  its  club-shaped  roots  deep  into  the  con- 
nective tissue,  which  they  force  apart  and  destroy  in  time  by  pressure. 
Within  these  spaces  are  found  small  fluid  accumulations,  resembling 
pus  and  serum,  in  which  are  suspended  broken-down  epithelial  and 
cancer  cells  undergoing  fatt}''  degeneration. 

When  these  fluid  accumulations  greatly  predominate,  we  have  Avhat 
is  called  medullary  or  soft  cancer,  but  if  scanty  the  tissues  are  then  so 
dense  that  the  disease  is  desi";nated  scirrhus. 


'492      CANCER  OF  UTERUS,  VAGINA,  RECTUM,  ETC. 

This  term  I  think  might  be  dispensed  with.  I  have  never  met  with 
any  such  condition,  and  regard  the  terra  as  one  which  was  in  use  to 
disguise  the  want  of  more  accurate  knowledge,  any  indurated  tissue 
being  designated  as  scirrhus. 

Epithelioma  and  carcinoma  may  coexist,  and  run  their  course  sepa- 
rately, but  this  is  exceedingly  rare.  For  although  the  growth  may 
seem  to  be  confined  to  the  cervix,  the  tissues  above  will  have  already 
become  infiltrated,  and  in  turn  break  down,  so  that  no  line  can  be  drawn, 
and  none  exists,  between  the  ulcerating  surfaces.  These  cancerous 
deposits  always  begin  to  soften,  or  break  down,  in  their  centre.  As 
they  increase  in  size,  inflammation  becomes  established  in  the  neigh- 
boring connective  tissue,  resulting  in  the  formation  of  abscesses,  which 
include  these  cancerous  deposits.  A  number  of  these  abscesses  come 
together,  by  destroying  the  intervening  tissue,  after  which  they  break 
and  discharge  their  contents,  leaving  a  sloughing  surface  exposed. 
New  tissue  is  constantly  becoming  involved  by  infiltration,  so  that  the 
sloughing  process  extends,  while  from  its  surface,  in  the  attempt  at 
repair,  new  growth  is  continually  springing  up,  to  be  in  turn  rapidly 
destroyed. 

Generally  the  first  symptom  which  will  lead  to  an  investigation  Avill 
be  a  sudden  loss  of  blood,  caused  by  the  first  breaking  down  of  tissue 
in  which  a  bloodvessel  has  opened.  This  process  is  early  accompanied 
by  a  watery  discharge,  which  becomes  exceedingly  offensive,  and 
afterwards  assumes  a  greater  consistency,  as  the  tissues  break  down, 
and  the  cancerous  matter  escapes. 

Etiology  of  Cancer. 

It  has  been  shown  by  observers  that  the  negro  in  this  country  is 
much  less  liable  than  the  white  woman  to  cancer  of  the  uterus.  This 
is  unquestionably  true,  and  I  can  add  my  professional  experience  in 
corroboration  of  it,  since  I  have  known  but  a  single  negro  woman, 
and  she  a  mulatto,  who  had  cancer  of  the  uterus.  My  own  belief  is 
that  cancer  of  the  uterus  is  to  be  found  more  frequently  among  the 
better  classes  than  among  the  poorer  ones,  and  that  white  women  of 
this  country  are  inflicted  with  this  disease  to  a  less  degree  than  the 
women  of  older  countries. 

Two  thousand  one  hundred  and  fifty-three  women  were  admitted  to 
the  Woman's  Hospital*  with  various  diseases,  of  which  number  sixty 

1  Twonty-second  Annual  Rei)()rt  of  tho  Woman's  Hospital  of  the  State  of  Now 
York,  containing  Dr.  John  N.  Bookman's  report. 


ETIOLOGY.  49-i 

liarl  cancer  of  the  uterus,  this  being  2.78  per  cent,  on  all  admissions. 
Two  thousand  four  hundred  and  forty-seven  women  in  my  private 
practice  suffered  from  different  sexual  disorders,  of  which  but  fifty- 
three  cases,  or  2.19  per  cent.,  Avere  cancer  of  the  uterus. 

"Within  the  past  five  or  six  years  some  restriction  has  been  placed 
on  the  indiscriminate  admission  of  these  cases  for  treatment  at  the 
Woman's  Hospital.  This  was  done  in  consequence  of  inadequate 
accommodations,  and,  while  the  restriction  may  have  made  some  dif- 
ference, it  could  be  but  slight.  For  all  cases  have  been  received 
regularly  when  they  could  be  placed  in  a  general  ward  without 
annoyance  to  others,  provided  there  was  any  reasonable  hope  of 
relief  from  an  operation.  But  in  my  private  practice  there  existed 
nothing  of  the  kind,  and  I  was  as  likely  to  be  consulted  for  cancer  of 
the  uterus  as  for  any  other  disorder  peculiar  to  women.  We  may, 
therefore,  accept  this  average  as  a  fair  one,  as  taken  from  a  class 
who  were  in  prosperous  circumstances  and  native  born,  for  the  ex- 
ceptions as  to  birth  are  too  small  in  number  to  affect  the  average. 

We  must  admit  our  lack  of  any  positive  knowledge  in  regard 
to  the  causes  of  cancer  of  the  uterus.  But  that  epithelial  cancer 
arises  frequently  from  perverted  nutrition,  in  the  attempt  to  repair 
injury,  cannot  be  questioned.  Those  who  suffer  from  this  form 
of  cancer  about  the  time  of  a  change  of  life  are,  without  exception, 
from  a  class  who  have  enjoyed  more  than  the  average  degree  of 
health.  Another  feature,  and  a  most  important  one  for  our  present 
purpose,  is  the  fact  that  the  average  number  of  children  borne  by 
these  women  is  always  much  above  the  usual  one.  In  connection 
with  these  facts  I  will  place  on  record  the  statement  to  the  effect 
that  I  have  never  known  a  woman  to  have  any  form  of  epithelial 
cancer  of  the  uterus  unless  she  had  at  some  time  been  impregnated. 
Moreover,  I  believe  that  nearly  all  if  not  all  cases  of  epithelioma,  or 
cauliflower  growth,  have  their  exciting  cause  or  origin  in  a  laceration 
of  the  cervix.  It  springs  from  the  effort  to  repair  a  local  injury,  as  I 
have  previously  stated,  and  may  develop  from  a  recent  laceration,  or 
it  may  occur  after  a  change  of  life. 

A  mass  of  granulations  may  spring  from  the  surfaces  of  a  recent 
laceration,  as  from  any  other  ill-conditioned  sore,  Avhen  due  to  the 
state  of  general  health,  or  to  any  other  cause.  Upon  this  foundation 
epithelioma  may  become  developed,  from  perverted  nutrition,  after 
the  first  child,  and  early  in  life.  That  such  a  growth  would  be  more 
liable  to  develop  in  after  life  can  be  readily  explained  on  physiolo- 
gical grounds.     An  entire  change  is  attempted  to  bring  about  a  con- 


494  CAXCER    OF    UTERUS,    VAGIXA,    RECTUM,    ETC. 

dition  in  the  uterus  fitting  it  for  the  quiescent  state  in  -which  it  is  to 
remain  during  the  after  period  of  life.  To  accomplish  this  the 
mucous  follicles  undergo  atrophy,  and  the  supply  of  hlood  gradually 
diminishes.  The  existence  of  an  old  cicatricial  mass,  such  as  would 
have  been  thrown  out  in  early  life  between  two  lacerated  surfaces  to 
prevent  their  rolling  out,  will  now  retard  the  process.  Frequently, 
such  a  mass  will  be  entirely  removed,  as  I  have  noticed,  with  great 
interest,  and  nature  will  even  undertake,  at  this  peinod  of  life,  the 
same  task  in  the  vagina.  But  the  natural  change  in  the  uterus  is 
sometimes  retarded  by  this  extra  duty,  and,  as  a  source  of  irritation, 
this  leads  to  a  fresh  supply  of  blood  being  sent  to  the  parts,  now  no 
longer  prepared  to  receive  it.  The  consequence  is  a  new  growth  is 
stimulated  on  this  epithelial  surface,  which  has  already  undergone 
marked  changes  in  its  character.  This  growth  may  be  at  first  benign, 
but  becomes  malignant  and  more  extended  by  striking  its  roots  deep 
into  the  uterine  tissue,  in  quest  of  needed  nutriment  which  the  mucous 
membrane  itself  cannot  now  supply. 

Fifty-one  women  in  my  practice  had  all  borne  a  number  of  children ; 
the  other  two  had  sufiered  from  the  eflfects  of  criminal  abortion  early 
in  life,  and  remained  sterile  afterwards.  Among  the  sixty  patients 
treated  for  cancer  in  the  "Woman's  Hospital  there  were  included  four 
cases  of  sarcoma.  Of  the  total  number  six  were  unmarried  (no  ques- 
tions were  asked  as  to  previous  pregnancies),  while  nine  were  reported 
as  sterile,  but  many  had  been  impregnated.  We  will,  therefore, 
exclude  the  sterile  women,  as  the  probabilities  were  all  in  favor  of  a 
miscarriage  or  criminal  abortion.  With  the  private  history  of  two  of 
these  unmarried  Avomen  I  happened  to  be  conversant,  and  sent  them 
to  the  institution.  They  were  about  forty  years  of  age,  and  had 
both  acknowledged  to  me  that  they  had  been  pregnant,  and  had  sub- 
mitted to  a  criminal  abortion  early  in  life,  from  the  efiects  of  which 
they  had  never  recovered.  The  others  were  not  in  my  service,  and 
may  have  suffered  from  sarcoma. 

With  our  present  limited  knowledge  on  this  subject  I  should  be 
sorry  to  be  instrumental  in  establishing  the  rule  that  epithelial  cancer 
of  the  uterus  was  proof  beyond  question  of  a  former  pregnancy.  No 
rule  we  are  told  is  without  exception,  and  this  may  not  be  an  excep- 
tion to  the  rule.  One  fact,  however,  we  may  accept  beyond  question, 
and  that  is  the  occurrence  of  this  form  of  cancer  in  a  woman  who  has 
never  been  impregnated  must  be  exceedingly  rare. 

This  fact,  together  with  the  large  average  number  of  children 
borne  by  these  women,  increases  the  circumstantial  evidence  in  favor 


LACERATION    AND    CANCER.  495 

of  the  supposition  regarding  the  consequences  of  lacerations  of  the 
cervix. 

Case  XX. — Some  seven  years  ago.  Dr.  Noeggerath,  of  this  city, 
sent  a  case  of  cauliflower  growth  to  the  AVoman's  Hospital  for  opera- 
tion. She  called  at  my  office  for  a  permit,  and  I  examined  her.  It 
so  happened  that  I  was  particularly  pressed  for  time,  and  in  making 
a  hasty  examination  I  caused  a  most  profuse  hemorrhage.  I  made 
various  applications  without  arresting  the  bleeding,  until  at  length  I 
placed  her  on  the  knees  and  elbows  so  as  to  be  able  to  bring  the  wliole 
growth  into  view,  over  the  surface  of  Avhich  I  placed  Avith  a  spatula 
more  than  a  large  tablespoonful  of  the  subsulphate  of  iron,  or  Monsel's 
salt,  and  a  tampon  over  it.  She  was  directed  to  inform  the  House 
Surgeon  to  remove  this  dressing  on  the  next  day,  but  she  neglected  to 
do  so,  and  it  remained  in  from  Friday  morning  until  the  following 
Thursday  afternoon.  The  Assistant  Surgeon,  Dr.  Harrison,  learning 
from  her  the  nature  of  her  malady,  did  not  make  an  examination, 
through  fear  of  causing  hemorrhage.  He  simply  directed  his  atten- 
tion to  her  general  condition  until  she  should  be  seen  by  me  in  the 
regular  routine.  To  my  astonishment,  when  I  removed  the  dressing, 
the  mass  of  granulations  had  disappeared,  showing  a  well-marked 
double  laceration  of  the  cervix.  She  was  two  or  three  months  under 
preparatory  treatment  for  the  purpose  of  reducing  the  size  of  the  uterus 
and  for  healing  the  torn  surfaces.  Afterwards  the  lacerated  portions 
were  united,  and  she  was  discharged  with  the  uterus  in  a  natural  con- 
dition. I  am  under  the  impression  that  she  visited  the  hospital  about 
eighteen  months  after  the  operation,  and  was  perfectly  well.  This 
result  might  have  followed  under  ordinary  circumstances  even  with 
true  epithelioma  ;  but  the  previous  existence  of  the  laceration  is  the 
point  I  wished  to  present. 

This  case  first  drew  my  attention  to  the  probable  connection  between 
laceration  and  cancerous  disease,  and  since  then  I  have  over  and  over 
again  verified  the  existence  of  the  injury.  In  fact,  I  have  never 
failed  to  detect  the  laceration  with  the  finger,  unless  the  disease  had 
so  far  advanced  as  to  already  involve  the  vaginal  surface. 

A  species  of  non-malignant  papilloma,  or  epithelioma,  which  is  some- 
times also  termed  cancroid,  is  found  occasionally  sprouting  up  from 
the  lacerated  surfaces  of  a  cervix,  like  a  mass  of  granulations.  To  the 
eye  the  appearance  is  like  that  of  cauliflower  growth  at  an  early  stage 
of  development.  But  the  mass  is  softer  and  less  friable  to  the  touch 
than  is  true  epithelioma  in  the  condition  we  generally  see  it  for  the 
first  time.  The  question  of  malignancy  is  only  determined  by  the 
extent  of  its  attachment,  as  has  been  already  described,  when  it  be- 
gins to  sink  its  roots  into  the  deeper  tissues.  This  change  may  take 
place  at  any  time,  and  the  short  period  before  it  occurs  constitutes  the 
only  one  at  which  cancer  in  any  form  may  be  said  to  be  local. 


496 


CANCER    OF    UTERUS,   VAGINA,   RECTUM,    ETC. 


Table  XXXVIII.  gives  the  earliest  and  latest  age,  at  time  of 
admission,  of  those  who  had  cancer  of  the  uterus,  together  with  the 
number  for  each  period  of  ten  years.  For  the  private  patients  the 
average  age  on  admission  was  43.01  years;  for  those  in  the  Woman's 
Hospital  only  an  approximation  is  given  in  the  table.  For  the  private 
patients  the  average  age  at  puberty  was  14.43  years,  being  a  little 
later  in  life  than  the  general  average;  that  of  marriage  was  19.41 
years. 

Table  XXXVIII Age  at  time  of  admission  of  those  who  suffered 

from  Cancer  of  the  Uterus. 


Private  Hospital. 

Number 
lor  each 
period. 

Woman's  Hospital. 

Number 
for  each 
period. 

Age  at  admission. 

Ago  at  admission. 

27  to  30      ..... 

30  "  40      

40  "  50       

50  "  60       

60  "  64 

3 

18 

21 

5 

6 

23  to  30 

30  "  40 

40  "  50       

50  "  60 

60  "  67 

6 
12 
21 
16 

4 

TotrJ     .... 

53 

Total     .... 

59 

In  the  Woman'' s  Hospital  Report  the  number  of  children  is  not 
given,  and  Table  XXXIX.  is  taken  from  the  records  of  the  private 
hospital.  The  number  of  children  ranges  from  one  to  ten,  and  there 
were  a  certain  number  of  miscarriages.  Thus  there  were  9  women 
Avho  had  1  child  each,  and  7  of  these  women  had  also  1  miscarriage 
each;  4  had  but  2  children  and  1  miscarriage  each  ;  10  had  3  chil- 
dren each,  and  12  miscarriages  in  all ;  2  women  had  each  1  miscar- 
riage and  no  children ;  and  11  women,  who  had  only  1  child  each, 
had  been  pregnant  18  times,  etc.  In  the  aggregate,  51  women  had 
228  children  and  44  miscarriages,  making  an  average  of  4.47  children, 
and  2.58  for  miscarriages  for  each.  Finally,  the  average  number  of 
impregnations  for  the  53  women  was  5.16  each,  which  is  nearly 
double  the  general  average. 

With  these  women,  an  average  of  13.87  years  had  elapsed  since 
their  last  pregnancy.  Nineteen,  or  85.84  per  cent.,  had  already  gone 
through  the  change  of  life,  at  the  average  age  of  44.95  years,  the 
extremes  being  for  the  earliest  39,  and  52  years  for  the  latest.  The 
average  length  of  time  since  the  first  symptom  of  the  disease  appeared 
was  a  little  over  11  months,  the  range  being  from  2  months  to  8 


PROGNOSIS. 


497 


years.  Thus  there  were  1  each  for  8,  G,  and  5  years;  3  for  B  years  ; 
6  for  2  years ;  11  for  1  year ;  and  the  remainder  were  below  this 
period.  The  growth  in  82  cases  was  confined  to  the  cervix,  in  3  in- 
stances to  the  anterior  lip,  and  in  the  same  number  to  the  posterior 
lip;  while  in  2(3  instances  both  lips  were  involved.  In  21  women  the 
body  of  the  uterus  was  the  seat  of  the  disease.  In  13  cases  the 
disease  was  confined  to  the  uterine  cavity,  and  in  8  it  had  also  ex- 
tended to  the  cervix.  The  cavity  of  the  uterus,  the  cervix,  and 
vagina  were  extensively  involved  in  5  of  these  cases,  the  bladder 
being  perforated  in  1,  and  the  rectum  in  another. 

Table  XXXIX. — Shotving  number  of  Pregnancies  among  53 
Women  with  Cancer  of  the  Uterus  (^Private  Hospital  Report). 


Number  of  children 

per  mother. 

> 
< 

1. 

2. 

.3.          i. 

5. 

6. 

7. 

S. 

9. 

10. 

No.  of  mothers 

9 

4 

10 

6 

5 

3 

5 

5 

1 

3 

51 

"      cbilJrea 

9 

8 

30 

21 

2j 

18 

35 

40 

9 

30 

228 

4.47 

"      miscarriages... 

7 

4 

12 

8 

6 

7 

•• 

44 

2.. 08 

2 

2 

1 

2 

2 

1.00 

"      miscarriages... 

Summary: 

No.  of  women 

11 

4 

10 

6 

5 

3 

?> 

.5 

9 

3 

.53 

"      pregnaacies  ... 

18 

12 

42 

32 

2.5 

24 

42 

40 

9 

30 

274 

.o.ie 

At  the  Woman's  Hospital,  when  the  cases  of  sarcoma  were  in- 
cluded, the  disease  was  found  situated  in  the  body  of  the  uterus  in 
10  instances,  confined  to  the  cervix  in  27,  and  both  body  and  cervix 
involved  in  23. 


Prognosis. 

Unfortunately,  we  have  as  yet  no  means  of  doing  more  than  to 
arrest  temporarily  the  progress  of  the  disease,  which  leads  inevitably 
to  death.  A  few  cases  are  on  record  where  the  uterus,  and  diseased 
tissues  about  it,  all  sloughed  away,  through  the  efforts  of  nature, 
with  recovery.  This  process  has  been  accidentally  established  during 
the  course  of  treatment,  and  with  the  same  fortunate  result,  in  several 
instances.  Cases  of  cure  have  been  also  reported,  as  the  result  of 
33 


498  CANCER    OF    UTERUS,    VAGINA,    RECTUM,    ETC. 

surgical  interference,  -when  no  return  of  the  disease  occurred.  But 
■svith  the  chances  so  much  against  a  probability  of  cure,  we  must  hold 
that  in  some  there  were  mistakes  in  diagnosis.  I  have  had  two  in- 
stances where  over  five  years  had  elapsed  after  the  operation  to  the 
time  when  I  lost  sight  of  them,  and  there  had  been  no  return  of  the 
disease.  Yet  I  am  fully  satisfied  that  I  committed  an  error  as  to  the 
diagnosis.  I  am  led  to  this  opinion  from  the  fact  that  in  every 
instance  Avhere,  at  the  time  of  the  operation,  no  doubt  existed  as  to 
the  nature  of  the  malady,  it  has  returned. 

The  tenacity  of  life  sometimes  shown  in  this  disease  is  remark- 
able. Br.  Barker^  had  under  his  care  a  lady  who  lived  in  good 
health  for  nearly  twelve  years  after  he  had  detected  the  existence 
of  cancer  in  the  uterus.  I  have  just  referred  to  cases  passing 
under  my  observation  where  the  disease  had  existed  for  eight,  six, 
five,  three,  two,  and  one  years,  according  to  the  statements  of  the 
patients.  If  these  could  be  relied  upon  as  to  the  beginning  of  hemor- 
rhage and  offensive  discharge,  the  disease  returned,  on  an  average, 
two  years  after  they  had  been  operated  on.  There  seems  to  be  a 
great  difference  of  opinion  among  observers  as  to  the  duration  of  this 
disease.  I  have  not  been  able  to  keep  any  reliable  data  on  this 
point,  but  my  impression  is  the  disease  returns  on  an  average  of  two 
years  after  removal,  and  that  it  runs  its  course  in  about  three  years. 

Diagnosis  and  Treatment  of  Cancer  of  the  Uterus. 

The  vaginal  examination  should  be  made  with  unusual  care  when- 
ever a  woman  is  suspected  to  be  suffering  from  cancer.  Unless  this 
rule  is  observed,  a  profuse  hemorrhage  will  always  occur,  and,  since  a 
most  thorough  examination  can  be  made  under  almost  all  circumstances 
without  any  loss  of  blood,  this  should  not  be  allowed  to  happen.  It  is 
only  necessary  to  pass  the  back  of  the  finger  along  the  posterior  Avall 
of  the  vagina,  while  at  the  same  time  the  perineum  is  pressed  back, 
with  the  view  of  introducing  air  into  the  vagina,  and  of  getting  beyond 
the  neck  of  the  uterus  without  touching  it.  If  the  passage  be  occu- 
pied by  an  enlarged  cervix,  or  a  mass  be  felt  growing  from  it,  the 
finger  can  be  applied  gently  to  the  surface  without  injury.  As  the 
finger  has  been  so  well  advanced  in  the  vagina,  it  is  able  to  examine 
every  part  by  simply  touching  it.     The  examination  unfortunately  is 

•  Some  Clinif-al  01)S<'rvations  on  tlic  Malignant  Diseases  of  the  Uterus,  by  For- 
dyce  Barker,  M.D.,  American  Journal  of  Obstetrics,  Nov.  1870. 


DIAGNOSIS.  499 

too  often  made  bj  pushing  the  finger  into  the  passage,  and  this 
always  breaks  through  the  thin  covering  to  the  bloodvessels. 

If  an  epithelioma  exists,  a  rough  friable  mass  will  be  detected, 
which  to  the  touch  Avill  resemble  nothing  else.  Other  growths  resemble 
this  in  appearance,  as  I  have  pointed  out,  but  they  are  soft,  and  none 
of  them  give  the  sensation  as  if  portions  of  the  mass  could  be  easily 
broken  ofi". 

If  the  disease  has  already  made  any  advance,  we  will  find  the  organ 
flexed,  more  or  less,  in  the  pelvis,  from  inflammation  which  has  been 
excited  in  the  cellular  tissue  by  cancerous  infiltration.  Should  the 
ulcerative  process  have  begun,  the  finger  will  be  able  to  pass  directly 
into  a  large  cavity  formed  below  the  internal  os,  which  has  already  in- 
volved the  cervix.  The  disease  necessarily  confines  itself  to  the  cervix, 
as  a  rule,  since  mucous  membrane  is  not  found  above  the  internal  os. 
The  lowest  part  of  the  vagina  will  be  found  filled  with  a  thin,  greasy, 
gruel-like  fluid  containing  portions  of  broken-down  tissue,  the  smell 
of  w^hich  is  so  marked  that  it  will  never  be  forgotten  after  it  has 
been  once  identified.  After  the  diagnosis  has  been  made  as  to  the 
character  of  the  disease,  the  next  most  important  point  to  determine 
will  be  the  extent  of  the  malady,  for  on  this  will  depend  the  course  of 
treatment  to  be  followed.  If  it  should  so  happen  that  the  disease 
has  not  yet  reached  the  vaginal  mucous  membrane,  but  is  still  con- 
fined to  the  cervix,  the  case  would  be  an  excellent  one  for  amputation. 
Should  the  vagina  have  become  involved,  the  uterine  cavity  some- 
Avhat  excavated,  the  organ  fixed  from  more  or  less  cellulitis,  with 
enlargement  of  any  of  the  lymphatic  glands,  to  be  found  generally 
behind  the  uterus,  and  to  either  side  of  the  pelvis,  we  can  only 
palliate  the  trouble.  After  completing  the  examination  the  physician 
will  urgently  desire  to  get  rid  of  the  smell  upon  his  hands.  I  know 
of  nothing  but  time,  literally,  and  a  solution  of  thymol  which  will  ac- 
complish it.  The  solution,  as  made  for  the  spray  apparatus,  to  be 
used  during  the  operation  of  ovariotomy,  will  answer,  or  even  a 
stronger  one  might  be  better,  and  it  should  be  kept  in  the  oflSce  for 
such  purposes.  A  solution  of  carbolic  acid  will  of  course  neutralize 
that  from  the  cancer,  but,  in  my  opinion,  there  is  little  choice  as  to 
odor  between  this  and  the  cancer. 

In  this  disease  there  should  be  no  delay  in  operating,  and  the 
patient  should  always  have  the  benefit  of  a  doubt  and  be  relieved  of 
any  suspicious  growth.  Whenever  this  is  limited  to  the  cervix  suffi- 
ciently to  warrant  its  removal  by  amputation,  it  should  be  done  with  the 
scissors  or  the  knife.    The  ^jraseur  or  galvanic  cautery  wire  should  not 


500      CAXCER  OF  riERUS,  VAGINA,  RECTUM,  ETC. 

be  employed  for  the  purpose.  If  Tve  are  able  to  get  into  healthy  tissue 
by  removing. the  neck  at  the  vaginal  junction,  we  should  aim  to  leave 
the  parts  in  as  healthy  a  condition  as  possible.  This  is  not  to  be 
accomplished  by  allowing  the  surface  to  heal  by  granulation.  I  have 
already  pointed  out  the  consequences  of  reflex  irritation  excited  by  a 
cicatricial  mass  being  formed  on  erectile  tissue.  Tissue  of  this 
character  is  of  so  low  a  grade  of  vitality  that  it  would  be  likely  to 
offer  a  better  starting-point  for  a  recurrence  of  the  disease  than  would 
be  found  in  more  highly  organized  stinicture.  It  is,  therefore,  good 
practice  to  make  a  clean  amputation  when  we  can  do  so,  and  to  cover 
the  stump  by  sliding  the  vaginal  tissue  over  it,  and  securing  the  edges 
of  the  flaps  with  sutures.  This  procedure  has  been  fully  described 
under  the  head  of  amputation  of  tbe  cer\ix,  and  the  full  details  of 
after-treatment  will  be  found  in  the  same  connection. 

Should  the  disease  have  advanced  already  so  far  that  the  woman 
may  be  judged  to  have  comparatively  no  future,  then  the  more 
thoroughly  the  diseased  tissues  can  be  destroyed  by  the  use  of  the 
cautery  the  better,  for  we  thus  employ  the  best  means  at  command  to 
prolong  life. 

The  patient  is  to  be  placed  on  the  left  side,  as  for  any  examination, 
and  the  largest  sized  Sims's  speculum  is  to  be  used.  I  first  remove 
rapidly,  with  the  scissors,  as  much  of  the  growth  as  I  can,  and  then 
employ  either  Thomas's  wire  scraper,  or  Simon's  curette,  or  scoop. 
Dr.  Sims's  scraper  has  too  sharp  a  cutting  edge,  and  causes  much 
bleeding.  With  some  one  of  these  instruments,  all  of  this  diseased 
tissue  must  be  scraped  away  until  apparently  healthy  tissue  has  been 
reached.  The  loss  of  blood  is  often  very  great,  but  it  can  be  held  in 
check  by  the  assistant  making  pressure  with  a  sponge  probang  against 
the  bleeding  vessel.  Or  several  long  artery  forceps  may  be  used  to 
secure  temporarily  the  mouths  of  the  larger  vessels.  Even  at  the 
expense  of  considerable  bleeding  this  work  must  be  thoroughly  done, 
for  a  partial  removal  would  only  be  a  fresh  stimulus  for  a  new  growth. 
In  fact,  unless  the  operation  be  thorough,  we  Avill  have  been  the  means 
of  shortening  the  life  of  the  patient.  After  all  the  diseased  portion 
has  been  removed,  the  cautery  must  be  applied  over  the  whole  raw 
surface.  The  actual  cautery  is  not  efficacious,  as  there  are  no  means 
of  keeping  up  the  white  heat,  and  I  have  thought  that  the  tissues 
contracted  more  and  became  more  dense  after  its  use  than  after  any 
other  application.  The  galvanic  cautery  is  better,  but  the  same  ob- 
jection, in  a  degree,  exists  in  regard  to  keeping  up  the  temperature. 

The  best  therrao-cautery  for  the   purpose  which  I  have  ever  em- 


TREATMENT.  501 

ployed  is  Paquelin's  instrument,  as  made  by  Charri^rc  in  Paris, 
liere  the  platina  cone  extremity  is  easily  kept  at  white  heat  by 
forcing  atmospheric  air  into  the  midst  of  a  flame  of  benzine  vapor, 
and  the  white  heat  is  maintained  with  but  little  impairment  even  in 
the  midst  of  profuse  bleeding. 

After  this  operation,  the  whole  surface  must  be  covered  by  a  thick 
pad  well  saturated  with  glycerine,  and  a  moderate  sized  tampon  placed 
over  all,  even  if  there  is  no  indication  of  bleeding.  The  necessity  for 
this  every  one  will  learn  by  experience,  and  I  would  urge  its  import- 
ance in  every  case.  The  patient  must  be  placed  in  bed,  and  not  dis- 
turbed until  the  second  day,  when  the  tampon  should  be  removed,  but 
not  the  pad  which  was  placed  in  contact  with  the  raw  surface.  This 
must  be  left  until  detached  by  suppuration,  for  if  removed  by  force, 
violent  hemorrhage  would  result.  About  an  ounce  of  glycerine 
thrown  in  with  a  glass  syringe,  along  the  sides  of  the  vagina,  when 
the  cotton  sticks  to  the  edge  of  the  denuded  surface,  will  aid  in 
loosening  it.  Five  or  six  hours  after  applying  the  glycerine,  a  vaginal 
injection  of  warm  water  will  generally  be  sufficient  to  loosen  this  mass 
of  cotton  so  that  it  can  be  taken  away  without  difficulty.  As  soon  as 
suppuration  begins,  which  will  be  indicated  by  the  increased  discharge, 
the  injections  are  to  be  employed  several  times  a  day  until  it  ceases. 
More  will  depend  upon  the  proper  use  of  these  injections  than  upon 
anything  else.  If  the  fetid  discharge  can  be  checked  by  keeping  the 
vagina  clean,  and  a  healthy  granulating  surface  established  on  the 
stump,  there  will  be  a  great  improvement  in  the  appetite  and  appear- 
ance of  the  patient.  In  fact,  after  such  an  operation,  it  is  sometimes 
difficult  to  divest  one's  self  of  the  impression  that  the  patient  has  not 
been  entirely  restored  to  health. 

It  is  remarkable,  both  as  to  the  extent  of  tissue  which  can  be  some- 
times removed  in  these  cases,  and  as  to  the  degree  of  tolerance  that 
the  system  evinces  to  such  a  procedure. 

Case  XXI. — Some  years  ago.  Dr.  Wm.  H.  Van  Buren,  of  this  city, 
saw  a  case  from  Baltimore,  in  consultation  with  me,  and  was  present 
at  the  operation.  This  lady  was  about  sixty  years  of  age,  and  had 
had  several  hemorrhages  from  the  vagina,  before  consulting  me. 

The  finger  passed  into  a  short  vagina,  about  two  inches  deep,  at  the 
bottom  of  which  was  felt  a  mass  of  cauliflower  growth,  involving  the 
neck  to  the  vaginal  junction,  where  the  passage  terminated  in  the  ab- 
sence of  a  posterior  cul-de-sac.  By  the  introduction  of  the  finger 
into  the  rectum  a  body  was  felt  as  if  it  were  the  retroverted  uterus 
somewhat  larger  than  would  have  been  expected  at  her  time  of  life, 
but  I  committed  a  great  oversight  in  not  completing  my  examination 


502      CANCER  OF  UTERUS,  VAGINA,  RECTUM,  ETC. 

by  a  conjoined  manipulation.  In  this  mass  on  the  cervix  I  detected  a 
small  opening  which  was  apparently  the  os,  but  the  probe  was  not  intro- 
duced through  fear  of  exciting  bleeding,  and  from  the  fact  that  I  felt 
thoroughly  satisfied  Avith  my  investigation  of  the  case. 

I  anticipated  no  difficulty  at  the  operation,  intending  to  cut  oif  only 
what  I  could  of  the  cervix  as  a  palliative  procedure,  and  then  cover 
the  stump.  As  soon  as  I  cut  into  the  supposed  neck  I  found  that  I 
had  made  a  mistake  in  diagnosis,  and  that  I  was  short-handed  for  the 
kind  of  operation  before  me.  The  bleeding  was  excessive  from  the 
besinnino- ;  there  was  no  alternative  but  to  continue  to  remove  the 
growth,  until  I  should  reach  comparatively  healthy  tissue.  Before 
this  was  done  the  vagina  and  uterus  had  opened  out  into  one  immense 
cavity  which  was  like  a  flaccid  bag.  I  was  unable  to  recognize  any 
part  of  the  cervix,  but  I  began  to  remove  the  growth  which  had  been 
mistaken  for  the  uterus,  and  Avhich  was  adherent  to  the  vaginal  walls, 
and  filled  the  posterior  cul-de-sac. 

This  I  followed  around  and  into  the  uterus,  until  there  remained  of 
the  organ  nothing  more  than  the  thinnest  shell.  I  used  scissors,  the 
curette,  and  finally  the  handle  of  one  blade  of  a  pair  of  long  scissors, 
which  could  be  disjointed,  and  it  proved  an  admirable  instrument 
for  the  purpose.  The  loss  of  blood  was  fearful;  it  was  sponged 
away  by  the  assistant  as  rapidly  as  possible,  but  the  quantity  was  so 
great  as  to  run  from  the  table  upon  the  floor.  Her  life  was  in  jeop- 
ardy, and  I  felt  that  there  could  not  be  more  than  a  temporary  security 
in  a  tampon  on  such  a  surface. 

From  a  short  distance  within  the  mouth  of  the  vagina  I  began  with 
a  needle,  having  a  long  silk  loop  attached,  to  go  around  this  cavity  in 
the  axis  of  the  vagina,  and  back  to  the  opposite  side,  taking  up  what 
tissue  I  could  at  about  the  distance  of  ever}"  inch.  I  introduced  six  or 
seven  of  these  running  strings,  radiating  like  the  sticks  of  a  fan,  a  long 
silver  wire  being  attached  to  each,  and  drawn  through.  The  two  ends 
of  the  suture  nearest  to  the  bladder  were  first  seized  in  one  hand 
and  held,  making  traction  as  the  tissues  were  being  slid  together  by 
the  finger  of  the  other  hand.  As  soon  as  the  parts  were  drawn  up 
tight  together  in  this  manner,  the  ends  of  the  sutures  were  twisted, 
bent  flat,  and  cut  oft"  short.  One  after  the  other  was  thus  secured 
from  above  downward,  so  that  the  blood  was  all  driven  out,  and  there 
could  be  no  accumulation.  The  hemorrhage  was  thus  arrested  perma- 
nently by  having  each  portion  of  raw  surface  folded  in  close  contact 
witli  some  other  part.  The  result  was  that  the  uterus  and  vagina 
were  all  drawn  up  into  a  solid  ball,  in  which,  to  my  surprise,  union 
took  place  throughout  by  the  first  intention.  I  could  only  find  after- 
wards two  or  three  of  the"  shorter  sutures,  and  the  patient  carried  the 
remainder  to  her  grave.  She  lived  scarcely  two  years  after  the  ope- 
ration, and  died  from  a  return  of  the  disease  in  the  neighborhood  of 
the  bottom  of  Douglas's  cul-dc-sac,  extending  thence  into  the  rectum. 
Her  life  was  prolonged  ])y  the  operation  and  saved  by  this  method  of 
brinsing  the  surfaces  together.     She  would  have  died  of  hemorrhage 


TREATMENT.  503 

if  the  attempt  had  been  made  to  control  it  by  a  tampon,  for  bleedino- 
woukl  have  come  on  each  time  it  was  removed. 

The  frequent  use  of  vanjinal  injections  will  greatly  lessen  the  odor, 
but  cannot  remove  it  entirely.  The  smell  of  the  carbolic  acid  is  almost 
as  disagreeable  as  that  from  the  cancer,  yet  it  is  invaluable  as  a  dis- 
infectant, and  should  be  added  to  each  injection.  In  the  use  of  a 
solution  of  thymol  for  injections  in  cancer,  I  have  had  an  experience 
limited  to  a  single  case  only,  and  I  know  of  no  one  else  who  has  em- 
ployed it  for  the  same  purpose.  It  will  prove,  I  am  fully  satisfied,  a 
most  valuable  agent  for  correcting  the  smell  of  cancer,  while  it  is  a 
perfectly  safe  remedy  and  unirritating.  The  proper  strength  has  not 
yet  been  determined,  but  it  will  be  needed,  I  think,  in  a  more  concen- 
trated form  than  the  formula  given  to  be  used  in  the  spray  apparatus. 
I  have  directed  a  few  ounces  of  this  strength  only,  to  be  thrown  into 
the  vagina  after  each  injection,  and  the  effect  has  been  marked.  A 
solution  of  the  permanganate  of  potash  is  a  good  deodorizer,  but  it  is 
liable  to  undergo  chemical  change,  and  should  be  freshly  made,  other- 
wise it  may  be  very  irritating. 

To  check  any  unexpected  bleeding  which  may  come  on,  I  direct 
that  a  saturated  solution  of  alum  shall  be  kept  by  the  patient  to  be 
injected  at  any  time.  An  ounce  or  two  thrown  into  the  vagina  while 
the  patient  is  on  the  knees  and  chest  will  prove  very  effectual.  When- 
ever the  woman  is  strong  enough  to  remain  for  a  few  moments  in  this 
position,  it  will  be  better  for  her,  as  the  alum  is  thus  kept  longer  in 
contact  with  the  bleeding  surface.  Afterwards  she  must  lie  quiet  on 
the  side  for  a  while. 

Whenever  an  injection  is  administered  with  the  patient  lying  on  the 
back,  the  nozzle  must  be  introduced  with  as  much  care  as  is  the  finger 
for  making  an  examination.  And  until  the  passage  has  become  dis- 
tended with  the  water  it  should  be  injected  without  force,  through 
fear  of  causing  hemorrhage.  Sometimes  a  piece  of  rubber  tubino- 
draAvn  over  the  nozzle  and  made  to  project  an  inch  beyond,  with  a 
few  holes  on  the  sides,  Avill  be  a  great  protection.  The  temperature 
of  the  water  used  for  these  injections  should  always  be  elevated, 
unless  there  should  exist  some  reason  to  the  contrary.  For  the  liio-ji 
temperature  will  be  particularly  serviceable  in  checking  bleeding,  and 
in  lessening  the  supply  of  blood  circulating  in  the  parts. 

The  thorough  application  of  Churchill's  tincture  of  iodine,  to  the 
entii'e  surface  of  the  cancerous  mass,  is  frequently  very  useful  in 
arresting  hemorrhage,  and  seems  to  have  the  effect  of  temporarily 
checkins  the  extension  of  the  disease. 


504      CANCER  OF  UTERUS,  VAGINA,  RECTUM,  ETC. 

Sometimes  one  of  the  earliest  symptoms  of  cancer  will  be  present 
in  the  form  of  pain  about  the  pelvis,  but,  as  a  rule,  it  is  only  when 
the  disease  has  advanced  that  the  patient  begins  really  to  suffer. 
It  is  incumbent  on  the  physician  to  use  his  best  judgment  in  the  admin- 
istration of  anodynes  in  such  a  disease  as  this,  and  the  patient  should 
not  be  allowed  to  suffer  through  the  fear  of  becoming  dependent  on 
them.  They  must  be  allowed,  and  as  the  disease  advances  the  patient 
must  receive  relief  regardless  of  the  quantity.  A  great  deal  may  be 
accomplished  if  the  selection  of  the  agent  and  dose  be  so  regulated  as 
to  gain  the  needed  eff"ect  without  disturbing  the  stomach  or  appetite. 
The  skill  of  the  physician  will  be  tested  in  accomplishing  at  first  all 
that  may  be  required  by  some  of  the  milder  remedies,  changing  from 
one  to  the  other  at  the  proper  time.  Chloral  will  agree  with  a  large 
number  of  persons,  and  answer  every  purpose  better  than  any  other 
remedy,  and  this  is  about  the  only  disease  in  which  I  ever  employed 
it  without  the  fear  of  serious  consequences.  Towards  the  close  of  the 
disease,  morphine  by  injection  under  the  skin,  and  by  suppositories 
in  the  rectum,  will  have  to  be  freely  employed. 

I  have  frequently  administered  iodoform  with  most  excellent  eifect, 
but  in  some  instances  there  has  not  been  the  slightest  benefit,  so  that 
I  have  long  since  regarded  the  remedy  as  an  uncertain  one.  In  the 
paper  which  has  been  referred  to.  Dr.  Barker  recommends  highly 
the  use  of  both  chloral  and  iodoform.  The  latter  remedy  he  employs 
in  the  form  of  a  vaginal  suppository  containing  ten  grains.  During 
the  discussion  of  Dr.  Barker's  paper  before  the  Academy  of  Medicine 
where  it  was  read.  Dr.  Peaslee  recommended  the  use  of  iodoform  in 
an  ointment  of  the  strength  of  one  drachm  to  an  ounce  of  lard.  This 
is  applied  freely  to  the  ulcerated  surfaces  "  with  the  effect  of  relieving 
pain,  correcting  the  fetor,  and  notably  diminishing  the  diseased  mass." 

For  constitutional  treatment  I  know  of  no  reliable  means  which  will 
exert  any  direct  local  effect.  Dr.  Barker  urged  the  use  of  arsenic  in 
the  form  of  small  doses  of  Fowler's  solution  for  its  constitutional 
effect.  This  agent  has  often  a  tonic  effect  by  improving  general 
nutrition,  but  I  have  never  recognized  any  local  change  which  could 
be  attributed  to  its  use. 

Dr.  Barker,  in  the  same  paper,  details  the  history  of  a  case  Avhere, 
after  he  had  applied  the  acid  nitrate  of  mercury  to  the  uterine  cavity, 
which  had  been  extensively  excavated  by  cancer,  a  prolonged  saliva- 
tion was  produced,  and  extensive  sloughing.  The  result  was  final 
recovery  of  the  patient,  after  the  uterus  and  the  surrounding  diseased 
tissue  had  become  destroyed.     In  a  foot-note  to  the  same   article,  as 


SARCOMA.  505 

published  in  the  Obstetrical  Journal,  is  given  the  history  of  a  similar 
result  following  the  use  of  the  acid  nitrate  of  mercury,  in  the  practice 
of  Dr.  iMettauer,  of  Virginia,  taken  from  the  Boston  Medical  and 
Surgical  Journal  of  March  10,  1870.  Dr.  Mettauer's  patient  was  a 
negress  who  was  married,  but,  as  stated,  had  never  conceived. 

Dr.  Routh,  of  London,  reported^  in  18(3(3  two  cases  of  cancer  cured 
by  the  use  of  an  alcoholic  solution  of  bromine.  As  this  agent  has 
not  come  more  into  use,  the  supposition  is  that  it  exerts  but  a  tempo- 
rary effect  in  arresting  the  progress  of  the  disease.  However,  if  the 
acid  nitrate  of  mercury  can  destroy  the  uterus,  and  save  a  life  occa- 
sionally by  "  eating"  out  the  entire  cancerous  mass,  bromine,  as  an 
equally  active  agent,  is  far  better  adapted  for  the  purpose.  To  apply 
bromine  to  a  comparatively  healthy  uterus,  or  to  one  in  any  other 
than  a  cancerous  condition,  should  never  be  thought  of.  Apart  from 
the  destruction  of  tissue  there  is  great  danger  from  cellulitis  or  peri- 
tonitis. But  in  cancer  this  danger  would  be  slight,  since,  from  an 
early  stage  in  the  progress  of  the  disease,  nature  attempts  to  protect 
herself  by  throwing  out  the  products  of  inflammation  in  advance.  If, 
therefore,  any  agent  can  be  made  useful  for  destroying  the  uterus 
and  surrounding  diseased  tissue,  bromine  is  the  best,  since  a  pecu- 
liarity of  its  action  is  in  its  greater  effect  upon  diseased  tissue  than 
upon  that  which  is  healthy. 

Sarcoma  of  the  Uterus. 

This  disease  may  present  itself  at  any  time  during  the  menstrual 
life.  It  originates  in  the  connective  tissue  of  the  uterus,  generally 
near  the  fundus,  and  is  of  slow  grow-th.  It  is  of  rare  occurrence,  and 
is  frequently  mistaken  for  carcinoma  or  epithelioma.  I  have  seen  but 
seven  cases,  all,  Avith  one  exception,  occurring  among  women  who  had 
never  borne  children ;  and  in  five  the  disease  developed  in  connection 
with  supposed  fibrous  growths.  All  of  these  women  had  been  under 
ray  care,  and  I  had  detected  the  existence  of  the  fibrous  growths  long 
previous  to  the  appearance  of  the  sarcoma.  Schroedei^  describes  a 
distinct  pedunculated  form  of  sarcoma  with  a  narrow  pedicle.  The 
cases  I  have  seen  were  but  outgrowths  from  the  uterine  surface,  with 
the  base  as  broad  as  any  other  portion.     I  therefore  doubt  this  as  a 

'  A  New  Mode  of  Treating  Epithelial  Cancer  of  the  Cervix  Uteri  and  its  Cavity, 
by  C.  H.  F.  Routh,  M.D.,  etc.— Transactions  of  the  Obstetrical  Society  of  London, 
vol.  viii. 

2  Ziemssen's  Cyclopaedia,  American  edition,  vol.  x. 


506      CANCER  OF  UTERUS,  VAGINA,  RECTUM,  ETC. 

distinct  form,  but  regard  it  rather  as  additional  proof  of  the  develop- 
ment from  fibrous  growths.  The  explanation  of  these  cases  presented 
by  Schroeder  is  most  likely,  that  the  sarcoma  developed  in  the  polypus 
after  the  tumor  had  become  pedunculated.  The  uterus  will  frequently 
detach  and  drive  out  the  growth  when  it  has  increased  in  size  suffi- 
ciently to  excite  it  to  contraction,  and  this  occurrence  is  generally 
mistaken  for  a  miscarriage.  But  it  is  scarcely  possible  that  a  growth 
of  the  consistency  of  sarcoma  could  ever  be  forced  by  the  action  of 
the  uterus  into  a  pedunculated  form,  with  so  slight  an  attachment  as 
Schroeder  describes. 

Sarcoma  develops  much  slower  than,  but  is  as  fatal  as,  any  other 
form  of  cancer.  Our  knowledge  of  the  disease  is  yet  too  limited, 
and  too  small  a  number  of  cases  have  been  put  on  record,  to  furnish 
us  with  accurate  information  as  to  its  laws  of  early  development  and 
after  growth. 

Diagnosis. — The  earliest  symptoms  of  sarcoma  will  be  a  watery 
discharge,  then  a  frequent  show,  out  of  time,  and  free  menstruation. 
The  discharge  has  been  compared  to  water  filled  with  meat  washings, 
and  is  not  alwaj^-s  offensive  as  with  other  forms  of  cancer  equally  far 
advanced.  As  a  rule,  there  will  be  but  little  pain,  except  sometimes 
in  the  back,  as  might  accompany  any  uterine  difficulty.  The  can- 
cerous cachexia  and  symptoms  of  blood  poisoning  come  on  at  the  last 
stages  of  the  disease.  A  vaginal  examination  will  only  establish  an 
enlargement  of  the  uterus,  with  no  indication  of  disease  about  the 
cervix.  Until  the  uterus  has  been  dilated  sufficiently  for  the  intro- 
duction of  the  finger,  we  cannot  form  a  diagnosis,  for  every  symptom 
may  be  due  to  a  uterine  polypus  undergoing  disintegration. 

When  the  finger  can  reach  the  fundus,  nothing  may  be  detected 
but  a  small  soft  mass  of  granulations,  not  unlike  epithelioma  in  its 
early  stages,  but  of  different  density.  In  the  recent  development  of 
the  disease  this  growth  may  be  mistaken  for  the  granulations  which 
are  frequently  found  in  women  Avho  have  had  a  number  of  children. 
The  microscope  may  establish  the  diagnosis  by  detecting  the  presence 
of  what  are  termed  the  spindle-shaped  cells  of  sarcoma,  each  containing 
one  or  more  large  oval  nuclei.  The  same  general  rules  arc  applicable 
for  the  treatment  of  sarcoma  that  have  been  already  given  in  full  for 
other  forms  of  cancer. 

Certain  points  in  diagnosis,  and  regarding  the  general  history,  have 
not  yet  been  fully  given,  being  withheld  to  be  presented  in  connection 
with  the  following  cases. 


CASES    OF    SAllCOMA.  507 

Case  XXIL — Mrs.  H.  B.  S.,  aged  29,  sterile,  was  admitted  to  my 
private  hospital  July  28,  I8O0.  She  menstruated  first  at  tiie  age  of 
10  years,  and  was  never  regular  afterwards.  Previous  to  her  mar- 
riage, at  19,  she  had  menstruated  hut  three  times.  Shortly  after 
marriage  she  began  to  suffer  from  hemorrhages  at  irregular  periods. 

I  found  the  uterus  enlarged  from  a  fibroid  in  the  anterior  wall,  but 
as  this  growth  was  too  small  to  account  for  the  size  of  the  uterus,  I 
dilated  the  canal  with  a  sponge  tent  a  few  days  after  her  admission. 
I  found  a  fibrous  polypus  about  an  inch  and  a  half  in  diameter, 
attached  by  a  short  pedicle  to  the  fundus,  and  I  removed  it  without 
difficulty.  For  two  years  she  menstruated  naturally  as  to  quantity. 
By  degrees  this  became  more  free,  until  at  length,  in  the  summer  of 
1867,  while  at  Beaufort,  South  Carolina,  where  her  husband  was 
stationed,  she  consulted  Dr.  Stewart,  who  removed  a  second  tumor 
which  was  soft  and  filled  the  cavity. 

Dec.  21,  1867,  she  was  admitted  to  the  Woman's  Hospital.  I 
found  a  soft  growth  as  large  as  a  hen's  egg  springing  from  nearly  the 
whole  anterior  wall,  and  filling  the  canal.  Dr.  Clymer,  who  Avas  then 
connected  with  the  institution,  made  a  microscopic  examination,  and 
pronounced  it  a  recurrent  fibroid. 

23(:Z.  I  removed  the  whole  mass  in  a  most  thorough  manner  down 
to  apparently  healthy  tissue,  by  means  of  scissoi's  and  a  scoop.  Then 
Churchill's  iodine  was  freely  applied  throughout  the  whole  canal,  with 
the  effect  of  causing  the  uterus  to  become  greatly  reduced  in  size. 
She  recovered  from  the  effects  of  the  ether  readily,  and  there  occurred 
nothing  special  to  mark  her  case. 

26fA,  Vaginal  injections  were  used  several  times  a  day  and  con- 
tinued from  the  first  discharge  after  the  operation.  She  made  a  good 
recovery,  and  went  home  Jan.  11,  1868. 

I  was  informed  afterAvards  that  the  growth  soon  returned,  as  was 
made  evident  by  the  recurrence  of  the  hemorrhages,  and  she  died 
Oct.  13,  1868. 

If  we  can  ever  be  certain  of  the  existence  of  a  fibroid  in  the  ute- 
rine walls,  I  was  as  to  this  tumor,  which  I  detected  between  three  and 
four  years  before  Dr.  Stewart's  operation  for  the  removal  of  the 
sarcoma  from  the  site  of  the  fibroid. 

Case  XXIII. — Mrs.  E.  D.,  aged  35,  Avas  admitted  to  the  Woman's 
Hospital  Oct.  15,  1867.  Menstruated  first  at  15,  was  generally 
regular  in  both  time  and  quantity  until  the  commencement  of  her 
present  difficulty.  Married  at  23  ;  had  had  one  child  and  five  mis- 
carriages. Four  years  and  a  half  previous  to  admission  she  began  to 
suffer  excruciating  pain  during  the  menstrual  period,  and  at  the  same 
time  from  menorrhagia.  She  received  no  treatment,  but  on  the  25th 
of  September,  1866,  something  seemed  to  burst  from  her,  and  a  large 
mass  came  aAvay  per  vaginam.  On  examination  this  Avas  pronounced 
a  hard  fibroid,  Avhich  had  become  enucleated  spontaneously.  For 
three  months  afterwards,  she  Avas  perfectly  Avell,  but  she  then  began 
to  flow  asain. 


508  CANCER    OF    UTERUS,    VAGINA,   RECTUM,   ETC. 

July  19,  1867.  Drs.  Peaslee  and  Sabine  removed  another  growth 
from  the  uterine  cavity,  which  was  supposed,  at  the  time,  to  be  an 
ordinary  fibrous  polypus.  There  was  but  little  improvement  after  the 
last  operation. 

Oct.  21.  I  dilated  fully  the  uterine  canal,  and  found  a  soft  mass 
springing  from  the  fundus  by  a  broad  base.  The  patient  was  placed 
under  the  influence  of  ether,  and  I  removed  the  entire  growth  with 
but  little  bleeding. 

A  portion  of  this  tumor  was  examined  by  Dr.  Francis  Delafield, 
who  stated  that  "  the  tumor  clearly  belonged  to  the  class  of  tumors 
described  by  Virchow  under  the  name  of  medullary  sarcoma."  (Such 
tumors  srowino;  from  the  mucous  membrane  of  the  uterus  have  been 
observed  at  times,  but  are  not  common.  The  prognosis  of  such  a 
tumor  is  bad,  less  so  on  account  of  secondary  growth  in  other  organs, 
than  on  account  of  its  certain  local  recurrence  and  the  consequent 
general  exhaustion  of  the  patient.) 

Nov.  8.  The  condition  of  the  patient  had  improved  sufficiently  for 
her  to  return  home.  The  record  of  her  case  gives  no  further  history, 
as  she  probably  never  returned  to  the  hospital.  My  impression  is 
that  she  died  shortly  after  her  return  home. 

Case  XXIV. — In  June,  1874,  I  was  sent  for  to  remove  a  uterine 
tumor  from  a  woman  residing  in  Stockholm,  N.  J.,  and  was  accom- 
panied by  Drs.  Bache  Emmet  and  Alfred  E.  M.  Purdy  to  assist  me. 
I  had  taken  it  for  granted  that  I  would  find  the  ^^terus  dilated  for 
the  operation,  but  this  had  been  neglected.  The  distance  was  too 
great  for  me  to  return,  and  it  was  necessary  to  do  something  speedily 
to  check  the  loss  of  blood  to  which  she  was  liable.  I  had  her  placed 
under  ether,  and  on  the  back  ;  then,  while  steadying  the  fundus  of  the 
uterus  with  one  hand  over  the  abdomen,  I  commenced  rapid  dilata- 
tion by  means  of  my  index  finger.  This  was  the  first  time  I  ever 
attempted  it,  but  I  soon  succeeded  in  working  the  finger  up  to  the 
fundus.  I  then  felt  a  soft  mass  of  granulations,  not  larger  than  the 
end  of  my  finger,  and  not  pedunculated.  These  were  easily  removed 
with  the  finger-nail  and  with  a  pair  of  forceps  I  have  for  the  purpose 
of  taking  away  other  granulations  from  the  uterine  cavity.  The  case 
then  seemed  of  little  importance ;  but  she  again  had  hemorrhages 
during  the  summer,  and  was  admitted  in  consequence  to  the  Woman's 
Hospital  October  15,  1874,  with  the  following  history: — 

Her  age  at  that  time  was  42.  She  had  menstruated  for  the  first 
time  at  the  age  of  18,  and  had  been  regular  afterwards.  She  had 
married,  and  was  sterile.  Her  health  had  been  good  luitil  four 
years  previous  to  her  admission,  when  she  began  to  flow,  and  then 
had  a  continuous  show  for  twenty-three  weeks.  Her  appearance  had 
greatly  changed  since  I  had  seen  her  in  June.  She  was  now  sallow 
and  cachectic;  had  had  several  chills  within  a  few  Aveeks  before 
entering  the  hospital ;  and  was  then  too  weak  to  sit  up  all  day. 

The  uterus  was  dilated ;  she  was  seen  by  Dr.  Sims  in  consultation, 
and  an  operation  was  decided  on.      Ether  was  administered,  and, 


CORRODING    ULCER.  509 

without  further  delay,  I  removed  with  forceps,  and  afterwards  the 
curette,  a  soft  mass,  as  large  as  an  English  walnut,  from  the  same 
point  of  the  fundus  from  which  I  had  before  taken  it  away.  The 
bleeding  was  very  profuse,  but  it  was  arrested  promptly  by  throwing 
hot  water  into  the  uterus  and  by  freely  applying  iodine  afterwards. 
Until  October  30  an  elastic  catheter,  attached  to  a  syringe,  was  passed 
to  the  fundus  daily,  and  the  cavity  thoroughly  washed  out  with  warm 
water  and  a  little  carbolic  acid.  As  the  discharge  was  rather  more 
profuse  than  is  usual  two  weeks  after  such  an  operation,  iodine  was 
freely  applied  to  the  fundus  by  means  of  the  applicator,  and  some 
cotton. 

Nov.  1.  At  2  A.  M.,  just  twelve  hours  after  this  application,  she 
was  seized  with  a  severe  chill  and  died  at  8  A.  M. 

The  post-mortem  examination  was  made  about  seven  hours  after 
death.  The  beginning  of  a  local  peritonitis  was  evident  from  the 
agglutination  of  the  intestines  about  the  uterus.  When  these  were 
sej)arated,  which  was  easily  done,  it  was  shown  that  a  portion  of  the 
fundus  had  begun  to  slough,  and  around  this  was  a  well-marked  line 
of  demarcation.  Although  soft,  this  plug  was  lifted  out,  by  a  little 
traction,  from  the  uterine  wall,  leaving  an  opening  about  an  inch  in 
diameter.  The  inner  face  of  the  plug  was  the  limit  of  the  base  from 
which  the  tumor  had  been  removed.  A  low  grade  of  inflammation 
was  no  doubt  established  by  the  operation,  which  involved  the  re- 
maining thickness  of  the  uterine  wall,  and  in  a  few  days  an  opening 
would  have  existed.  Either  some  fluid  did  escape  into  the  peritoneal 
cavity,  or  the  softening  process  excited  the  local  inflammation  in  the 
peritoneum.  She  was,  however,  rapidly  dying  from  blood  poisoning, 
so  that  it  would  have  required  but  a  slight  shock,  at  any  time,  to  have 
caused  death. 

Corroding  TJlcer. — An  ulcerative  process  attended  with  great  de- 
struction of  tissue,  which  is  supposed  to  originate  on  the  cervix.  It 
may  extend  within  the  cavity,  but  is  usually  confined  to  the  walls  of 
the  vagina,  through  which  it  often  penetrates  into  either  the  bladder 
or  rectum.  It  may  sometimes,  in  the  same  subject,  open  into  both 
cavities,  for  such  cases  have  been  recorded,  but  I  have  never  known 
of  an  instance.  This  form  of  cancer  is  almost  as  rarely  met  with  as 
true  sarcoma.  We  know  nothing  of  its  early  stage,  since  it  is  always 
far  advanced  before  any  suspicion  arises  of  its  existence.  The 
disease  seems  to  be  confined  to  those  who  have  been  frequently  preg- 
nant, and  arises  about  the  time  of  the  final  cessation  of  menstruation. 

Hemorrhage  is  one  of  the  first  symptoms,  and  its  significance  may 
for  a  time  be  overlooked  by  attributing  its  occurrence  to  a  change  of 
life.  There  is  frequently  no  pain,  and  consequently  medical  advice 
may  not  be  sought  until  the  coming  on  of  the  thin  and  off"ensive 
vaginal  discharge,  which  always  accompanies  cancerous  ulceration  in 


510  CANCER    OF    UTERUS,    VAGINA,    RECTUM,    ETC. 

every  form.  As  the  disease  advances,  the  effects  are  verj  similar  to 
those  of  cancer  generally  in  the  cachectic  condition:  there  is  increase 
of  pain,  loss  of  flesh  and  appetite,  with  dyspepsia  and  constipation, 
and  death,  at  last,  from  exhaustion,  or  from  the  shock  attending  some 
sudden  attack  of  peritonitis.  Yet,  among  those  suffering  from  corroding 
ulcer,  there  will  be  many  more  exceptions  to  every  rule  than  there  are 
among  those  with  any  other  form  of  cancer  of  the  uterus.  I  have 
seen  two  or  three  instances  where  no  pain  was  experienced  from  the 
beginning  to  the  end,  and  when  the  patients  died  from  sudden  attacks 
of  inflammation,  brought  on  by  the  spread  of  the  disease,  they  seemed 
to  be  in  perfect  health.  After  they  had  learned  to  keep  themselves 
clean,  and  to  check  any  sudden  bleeding,  they  were  able  to  get  as 
much  enjoyment  out  of  life  as  the  average  number  of  women  in  good 
health.  I  think,  as  a  rule,  women  suffer  less  pain,  and  that  the 
progress  of  the  disease  is  much  slower,  with  corroding  ulcer  than  with 
cancer  proper. 

Case  XXV. — I  was  consulted  several  years  ago  by  a  lady  71 
years  of  age,  who  was  then  in  good  health  for  one  at  her  time  of  life, 
and  yet  she  had  had  this  disease  for  probably  tAventy  years.  This  I 
judged  had  been  the  case  from  the  symptoms  Avhich  were  presented, 
while  already  nine  years  had  elapsed  since  the  labia  had  been  de- 
stroyed by  the  advance  of  the  disease  from  the  vagina.  In  her  case 
there  had  been  no  loss  of  blood  for  many  years,  so  long  in  fact  that 
she  could  give  no  approximation  as  to  the  time.  I  found  on  making 
a  vaginal  examination  that  every  thing  seemed  to  have  been  destroyed 
but  the  bladder  and  urethra,  and  yet  she  understood  so  well  how  to 
take  care  of  herself,  that  no  one  would  have  had  the  slightest  sus- 
picion of  her  condition.  Her  position  in  society  was  well  known  to 
me,  and  I  have  not  the  slightest  doubt  as  to  the  accuracy  of  her 
statements.  She  lived  for  some  eighteen  months  after  I  saw  her,  but 
I  was  never  able  to  ascertain  the  immediate  cause  of  her  death. 

Diagnosis  and  Treatment. — There  Avould  be  but  little  difiiculty, 
from  the  history  of  any  case,  to  ascertain  that  malignant  disease 
existed,  but  without  an  examination  it  would  not  be  easy  to  determine 
the  form.  We  will  find  the  same  offensive  sero-pus-like  discharge. 
With  the  finger  the  outline  of  the  ulceration  can  be  distinctly  traced, 
since  (and  it.  is  a  peculiarity  of  all  cancerous  ulcerations)  the 
surface  breaks  down,  and  is  always  below  the  level  of  the  surround- 
ing healthy  tissue.  On  the  introduction  of  the  speculum,  the  ulcera- 
tion will  appear  as  a  roughened  surface  of  a  dirty  grayish-brown 
color,  surrounded  by  a  perfect  line  of  demarcation.  The  vdcerated 
surfaces  terminate  by  a  narrow  but  marked  red  line  directly  in  con- 


CANCER  OF  THE  RECTUM.  611 

tact  with  perfectly  healthy  tissue.  In  this  disease  we  never  find 
cancerous  infiltration  in  the  neighboring  tissues ;  the  uterus  is  generally 
of  a  natural  size  and  perfectly  movable,  except  as  in  last  stages  of  the 
disease,  a  recent  attack  of  inflammation  may  have  been  established. 

I  have  nothing  to  add  to  the  general  plan  of  treatment  already 
given,  there  being  the  same  necessity  for  the  most  perfect  cleanliness, 
to  keep  up  the  general  health,  and,  when  necessary,  to  relieve  the 
suffering  of  the  patient  by  the  judicious  use  of  anodynes.  If  the  dis- 
ease be  seen  at  a  comparatively  early  stage,  I  would  recommend  the 
most  thorough  application  of  the  cautery.  There  exists  but  little 
hope  of  eradicating  it,  but  we  are  often  able  to  delay  its  progress  by 
this  means. 

Cancer  of  the  External  Organs  of  Generation. — But  little  in 
addition  need  be  stated  in  relation  to  cancer  of  the  external  organs  of 
generation.  It  is  sometimes  limited  to  the  clitoris,  but,  as  a  rule,  the 
disease  is  in  the  form  of  the  corroding  ulcer  extending  from  the  vasrina. 
This  form  of  cancer  has  been  termed  rodent  ulcer,  and  by  some  lupus 
from  its  resemblance  to  lupus  in  other  parts  of  the  body.  But  I 
regard  all  forms  of  cancer  found  at  the  outlet  of  the  vagina  as  corrod- 
ing ulcer  or  epithelioma,  modified  somewhat  by  the  diiference  of  tissue. 

Any  suspected  growth  on  the  labia  should  be  extirpated  without 
delay,  while  the  parts  are  yet  movable.  The  edges  of  the  w^ound 
must  be  brought  together  and  secured  by  silver  sutures.  This  will 
check  any  amount  of  bleeding  not  excessive,  and  leave  but  a  cicatricial 
line  after  the  process  of  healing  has  terminated.  But  if  bleeding 
should  recur,  it  can  be  arrested  promptly  by  placing  a  rolled  compress, 
the  size  of  the  finger,  on  each  side  of  the  suture  and  securing  these 
by  a  T  bandage. 

Cancer  of  the  Rectum. — I  do  not  intend  to  treat  of  cancer  of  the 
rectum,  since  it  is  not  strictly  within  the  scope  of  this  work,  but  I 
wish  to  place  on  record  the  description  and  after  history  of  an  opera- 
tion which  is  of  interest  in  connection  wdth  this  subject. 

Case  XXVI. — Mrs.  M.  D.,  aged  35,  was  admitted  to  the  Woman's 
Hospital  April  1,  1871.  She  had  borne  seven  children,  and  had  one 
miscarriage  ;  the  last  pregnancy  was  four  years  previous  to  admission. 
Her  labors  had  all  been  difficult,  and  with  her  miscarriage  she  had  a 
great  loss  of  blood,  and  suffered  from  pain  afterwards  ;  was  confined 
to  her  bed  for  seven  weeks.  After  this  miscarriage  she  never  re- 
gained her  health,  but  had  a  great  deal  of  backache,  pressure  on  the 
bowel,  pain  down  the  right  leg,  with  prolapse  of  the  anus  for  a  year 
afterwards. 

At  thje  time  of  her  admission  the  period  was  regular,  but  frequently 


512      CANCER  OF  UTERUS,  VAGINA,  RECTUM,  ETC. 

lasted  two  weeks.  Her  chief  complaint  was  a  feeling  of  an  uneasy 
sensation  in  the  lower  part  of  the  back  near  the  anus,  which  was 
accompanied  by  a  frequent  desire,  sometimes  as  often  as  five  or  six 
times  daily,  to  evacuate  the  bowels.  This  feeling  had  existed  about 
two  years  prior  to  admission.  But  from  the  previous  Christmas  she 
had  been  subjected  to  pain  of  a  sharp  lancinating  character,  which 
was  not  continuous.  Her  suffering  had  become  so  great  within  a 
short  time  that  she  was  unable  to  sleep  or  do  an3^thing  Avithout  being 
all  the  time  under  the  influence  of  opium.  This  had  already  affected 
her  general  health,  for  she  had  become  pale,  and  had  lost  both  flesh 
and  strength,  so  that  she  spent  the  greater  portion  of  her  time  in  bed. 

At  length  she  consulted  Dr.  Sims,  who  discovered  a  hard  circum- 
scribed mass  the  size  of  a  hen's  egg,  occupying  the  posterior  wall  of 
the  rectum  an  inch  above  the  sphincter,  very  painful  to  the  touch. 
There  was  no  discharge  from  this  mass  in  the  bowels  at  the  time  of 
the  examination.  Dr.  Sims  removed  a  portion,  and  as  the  microscope 
showed  it  to  be  epithelial  cancer,  he  advised  her  to  enter  the  Woman's 
Hospital,  then  in  my  charge. 

I  found  the  mass  as  described  above,  and  I  could  distinctly  trace  it 
out  to  its  limits,  but  below,  just  within  the  sphincter,  and  surrounding 
the  gut,  so  as  to  include  about  an  inch  of  the  recto-vaginal  septum, 
the  tissues  felt  as  if  infiltrated  with  serum.  The  muscle  itself  was 
more  rigid  than  usual,  and  the  examination  gave  her  a  great  deal  of 
pain.  The  mass  was  evidently  increasing  in  size,  very  sensitive  when 
touched,  and  filled  up  the  passage  to  such  an  extent  as  to  seriously 
obstruct  the  canal.  No  enlargement  of  the  glands  could  be  detected, 
and  I  decided  to  remove  the  mass. 

April  17.  Operation.  Present,  Drs.  Sims,  Wm.  H.  Van  Buren, 
James  R.  Wood,  and  others.  After  the  patient  had  been  etherized, 
the  sphincter  ani  muscle  was  fully  dilated  by  stretching,  so  as  to 
enable  me  to  get  at  the  mass  with  greater  facility.  It  was  then 
drawn  down  by  means  of  a  double  tenaculum,  and  held  by  an  assist- 
ant. A  steel  grooved  director,  as  the  most  convenient  instrument  for 
the  purpose,  was  pushed  through  the  skin  in  front  of  the  coccyx  and 
just  behind  the  outer  edge  of  the  sphincter,  into  the  cellular  tissue  of 
the  pelvis,  and  then  made  to  puncture  the  rectum,  in  healthy  tissue, 
just  beyond  the  upper  edge  of  the  tumor.  The  end  was  turned  out 
of  the  gut  and  pushed  far  enough  forward  to  rest  on  the  perineum 
while  the  other  end  was  over  the  coccyx.  Then  a  second  director 
was  passed  around  from  the  outer  side  of  the  muscle  on  one  side, 
through  the  cellular  tissue  into  the  rectum,  across  to  the  other  side, 
through  the  cellular  tissue  and  skin  again  to  the  opposite  side  of 
the  muscle.  •  So  that  the  mass,  with  a  portion  of  the  rectum  above, 
was  now  brought  through  the  anus  and  fixed  by  the  two  directors, 
which  had  been  passed  behind  the  mass  at  right  angles  to  each  other, 
with  their  ends  resting  outside  on  the  soft  parts.  The  chain  of  an 
^craseur  was  placed  behind  these  two  instruments  and  slowly  tight- 
ened until  tlie  whole  mass,  as  transfixed,  Avas  cut  through  along  the 
course  of  the  directors.    By  this  means  I  removed  the  entire  sphincter 


CANCER  OF  THE  RECTUM.  513 

muscle,  about  three  inches  of  the  posterior  wall  of  the  rectum,  and 
about  an  inch  and  a  half  of  the  rectal  surface  of  the  recto-vaginal 
septum.  The  immediate  result  was  a  most  formidable  opening  in  the 
connective  tissue  of  the  pelvis,  about  three  inches  in  diameter,  and 
cone-shaped  from  below.  There  was  not  the  slightest  bleeding  at  first, 
but  I  detected  a  hard  mass  a  little  to  one  side,  as  if  it  were  a  lym- 
phatic gland,  which  I  snipped  oif  with  a  pair  of  scissors.  I  at  once 
realized  my  mistake,  for  I  had  opened  a  vessel  of  large  size,  and  as 
it  retracted  deeper  into  the  cellular  tissue  I  could  not  secure  it  by  a 
ligature.  I  placed  over  the  surface  a  thick  compress  of  cotton,  Avhich 
had  been  wet  Avith  alum  but  squeezed  dry,  and  then  introduced  over 
this  a  vaginal  glass  plug  fully  two  inches  and  a  half  in  diameter. 
Finding  that  this  arrested  the  bleeding,  it  was  covered  in  front  by 
a  compress  of  a  towel  rolled  up,  and  a  T-bandage  over  all. 

For  several  days  following,  there  was  very  marked  febrile  reaction, 
with  excruciating  pain  from  the  continued  pressure  of  the  glass  plug, 
so  that  it  was  necessary  to  keep  her  all  the  time  fully  under  the  in- 
fluence of  opivim.  As  the  catheter  could  be  introduced  by  slightly 
depressing  the  edge  of  the  plug,  this  instrument  was  not  disturbed 
until  April  20,  when  suppuration  having  begun,  the  plug  and  cotton 
tampon  could  be  removed  with  safety.  This  was  followed  by  a  profuse 
brown  discharge  Avithout  odor.  The  passage  was  then  syringed  out 
gently  Avith  a  Aveak  solution  of  carbolic  acid  and  warm  water,  to  the 
great  relief  of  the  patient.  That  afternoon  the  bowels  were  moved 
naturally,  she  Avas  conscious  of  the  passage  but  had  no  power  of  con- 
trol. No  further  treatment  Avas  needed,  except  the  administration  of 
an  injection  several  times  a  day. 

April  23,  the  boAvels  Avere  moved  again,  butAvith  considerable  pain. 
April  29,  the  boAvels  continued  to  act  regularly,  though  Avhen  moved 
she  suffered  pain,  and  had  a  free  broAvnish  discharge  afterwards.  The 
use  of  opium  had  been  steadily  diminished  from  excessive  doses  to 
ni,  XX.  of  Magendie's  solution  daily ;  she  noAv  began  to  sit  up.  May  15, 
the  Avound  had  almost  entirely  healed,  the  patient  Avalking  out,  feeling 
well,  with  improving  retentive  poAver,  but  still  some  slight  pain  after 
every  moA-ement  of  the  boAvels.  Discharged  June  5,  surfaces  all 
healed,  Avith  good  retentive  poAver,  and  the  parts  free  from  induration. 
As  the  healing  process  advanced  and  the  surfaces  contracted,  the 
healthy  gut  above  Avas  draAvn  doAvn,  and  brought  nearly  in  contact 
with  the  external  parts.  She  promised  to  return  in  a  fcAv  weeks,  as  I 
feared  the  entrance  to  the  gut  Avould  close  by  contraction,  when  I  de- 
termined to  make  an  opening  into  the  vagina. 

She  returned  at  the  end  of  eighteen  months  to  say  that  she  was  per- 
fectly Avell.  Six  months  later,  she  called  for  the  same  purpose,  Avhen 
I  detected  a  moA^able  mass,  about  half  an  inch  in  diameter,  in  the  por- 
tion of  the  recto-vaginal  septum  Avhich  was  not  remoA'ed.  I  wished  to 
operate  at  once,  but  it  Avas  three  months  before  she  could  make  up  her 
mind,  as  she  was  feeling  perfectly  Avell.  I  then  found  it  had  reached 
to  the  sigmoid  flexure ;  she  Avas  already  beginning  to  be  poisoned  by  the 
accumulation  in  the  colon.  I  proposed  colotomy  for  her  relief,  but  she 
would  have  nothing  more  done,  and  died  a  foAV  Aveeks  afterwards. 
33 


514  DESCRIPTION,   ETIOLOGY,   AND    DIAGNOSIS    OF 


CHAPTER    XXVII. 

DESCRIPTION,  ETIOLOGY,  AND  DIAGNOSIS  OF  FIBROUS  GROWTHS 
OF  THE  UTERUS. 

Mode  of  formation — Etiology — Tables  XL.  to  LII.  iuclusive — Diagnosis. 

A  FIBROUS  growth  has  its  origin  within  the  muscular  tissue  of  the 
uterus,  and  is  generally  of  a  dense  structure,  but  not  always,  and  it 
may  or  may  not  undergo  cystic  degeneration. 

Such  a  tumor  may  remain  as  an  isolated  mass  within  the  uterine 
tissue,  being  limited  in  growth,  or  it  may  gradually  involve  the  greater 
portion  of  the  organ,  attaining  an  almost  unlimited  increase  in  bulk. 

A  fibrous  tumor  of  the  uterus  has  been  termed  a  "  fibro-myoma"  by 
Virchow,  a  "  fibroid"  by  Rokitansky,  and  "  a  partial  hyperplasia  of 
the  uterine  parenchyma"  by  Klebs. 

While  small,  such  a  growth  may  be  designated  a  fibroid ;  when 
larger,  and  out  of  the  pelvis,  a  fibrous  tumor,  or  a  fibrous  growth 
of  the  uterus,  without  reference  to  the  degree  of  development. 

As  an  exceptional  circumstance,  an  accumulation  of  fluid  sometimes 
occurs,  within  certain  portions  of  these  growths,  and  then  they  are 
said  to  have  undergone  cystic  degeneration.  But  should  this  process 
become  so  extensive  as  to  involve  the  whole  mass,  leaving  but  little 
of  the  fibrous  element,  it  is  then  termed  a  fibro-cystic  tumor. 

According  to  Klebs, ^  "  Microscopic  investigations  show  that  the 
chief  mass  of  the  tumor  consists  of  smooth  muscular  fibres  which  con- 
siderably exceed  in  size  those  of  the  unimpregnated  uterus."  "  The 
muscular  fibres  are  arranged  in  bundles,  and  the  latter  unite  variously 
at  acute  angles  to  form  larger  groups,  which  enclose  a  wide  capillary 
bloodvessel.  The  walls  of  the  latter  consist  of  a  simple  layer  of  endo- 
thelium cells  with  large  nuclei,  and  are  supported  by  a  thin  layer  of 
fibrous  connective  tissue,  from  which  processes  penetrate  between  indi- 
vidual groups  of  muscular  bundles,  and  unite  with  coarse  partition 
■walls  between  the  individual  vascular  districts.  Between  the  muscu- 
lar bundles,  as  well  as  between  these  and  the  connective  tissue  sheaths 

'  llandljucli  der  pathologischen  Aiiatomie.    Von  Dr.  E.  Klebs,  vierte  Lieferung. 


FIBROUS    GROWTHS    OF    THE    UTERUS.  515 

of  the  vessels,  may  be  observed  everywhere,  by  careful  treatment, 
narrow  slit-like  gaps,  which  here  and  there  contain  Avhite  blood  cor- 
puscles, and  are  surrounded  by  a  fine  boundary  line,  within  which, 
here  and  there,  lie  nuclei.  A  cavernous  structure  thus  originates, 
which  is  not  found  in  the  normal  uterine  tissue,  and  it  is  very  proba- 
ble that  these  cavities  are  to  be  regarded  as  lymph  spaces  in  which 
the  bloodvessels  and  muscular  bundles  are  suspended,  as  it  were,  by 
fine  bands  of  connective  tissue." 

"  The  further  increase  in  size  of  these  tumors  ensues  rarely  by  the 
coalescence  of  several  of  them  ;  more  frequently  it  takes  place  by 
the  same  process  being  repeated  which  gave  rise  to  the  smallest  and 
simplest  fibro-myomata.  Each  individual  vessel,  with  the  muscular  and 
connective  tissue  masses  belonging  to  it,  proliferates  again  and  forms, 
as  it  were,  a  second  generation  of  nodules,  which  are  imbedded  in  the 
original  tumor  and  distend  the  latter." 

"  Not  rarely  their  disposition  is  such  that  the  tumor  is  arranged  in 
the  form  of  wedge-shaped  lobes  around  the  centrally  situated  large 
vascular  trunks,  the  broad  bases  of  which  lie  on  the  surface.  In 
other  cases  the  formation  of  secondary  nodules  occurs  only  in  par- 
ticular places  of  the  tumor,  and  these  originate  quite  irregular 
tuberous  forms.  These  peculiar  inner  processes  of  growth  lead  now 
to  dislocations  of  the  tumors,  all  of  which  had  a  common  origin  in  the 
muscular  tissue  of  the  uterus.  If  increase  in  the  parts  adjacent  to 
the  mucous  or  serous  membranes  ensues,  especially  in  nodules  super- 
ficially situated,  the  latter  elevate  themselves  above  the  surface  and 
finally,  sustained  by  the  increasing  weight,  project  entirely  beyond 
the  surface.  In  this  way  fibro-myomata  originate,  which  either  are 
suspended  by  a  narrow  pedicle  quite  beyond  the  uterine  Avail  (extra- 
mural fibro-myomata),  or  the  connection  with  the  latter  is  more  ex- 
tensive through  a  looser  layer  of  tissue  pervaded  by  Avide  venous 
sinuses.  In  the  latter  case  the  dilated  veins  can  frequently  be  traced 
through  the  entire  thickness  of  the  uterine  Avail.  Further  differences 
in  the  structure  of  these  tumors  are  occasioned  by  the  preponderating 
development  of  one  of  their  histological  constituents,  and  by  degene- 
rative processes.  In  regard  to  the  first  series,  each  tissue  partici- 
pating in  the  formation  of  the  fibro-myoma  can  displace  the  rest. 
Most  frequently  this  takes  place  on  the  part  of  the  connective  tissue, 
whereby  the  entire  tumor  becomes  denser,  firmer,  more  fibi'ous  ;  the 
lymph  spaces  and  bloodvessels  Avithin  the  tumor  are  narroAved  and 
partly  obliterated ;  the  smooth  muscular  bundles  are  preserved,  but 
the  individual  fibres  can  no  longer  be  recognized  separately  ;  in  their 


616  DESCRIPTION,    ETIOLOGY,    AND    DIAGNOSIS    OF 

place,  very  narrow,  long,  rod-like  nuclei  lie  embedded  in  a  striated 
basis  substance.  Accordingly,  even  in  this  stage  of  development, 
the  tumor  cannot  at  all  be  pronounced  a  pure  fibroma.  Its  biological 
activity  is  herewith  closed,  and  these  are  just  the  forms  in  which 
degenerative  processes  appear.  A  preponderating  development  of 
the  muscular  tissue,  Avhich  would  stamp  the  tumors  as  pure  myomata, 
is  rare ;  in  general,  the  formation  of  the  muscular  substance  runs 
parallel  "with  the  vascular  development,  and  the  richer  nutritive 
supply  thereby  originating  ;  yet  tumors  also  occur  which  from  the 
outset  consist  almost  entirely  of  smooth  muscular  fibres,  possess  the 
grayish-red,  dimly  transparent  appearance  of  normal  uterine  muscular 
tissue,  and  are  evidently  contractile." 

"In  a  like  hyperplastic  way  can  the  vessels  of  the  fibro-myomata 
develop ;  the  lymph  spaces  dilate  to  smooth-walled  cysts,  destitute  of 
a  special  membrane,  and  filled  with  clear  limpid  fluid.  The  process 
begins  in  the  centre  of  the  tumor,  in  the  immediate  neighborhood  of 
the  larger  vessels,  and  the  cysts  frequently  exhibit  narrow  processes, 
which  are  prolonged  into  the  connective  tissue  partition  walls  between 
the  individual  nodules,  or  there  are  formed  here  swollen  cysts  placed 
in  rows.  Cystic  fibro-myomata  of  the  uterus  can  attain  very  consider- 
able size,  especially  when,  as  may  frequently  happen,  heterologous, 
especially  myxomatous  and  sarcomatous,  new  formations  become  asso- 
ciated Avith  them.  But  also  simple  cysts  of  considerable  size  are 
known,  which  are  surrounded  on  all  sides  by  muscular  svibstance. 
Their  contents  then  are  usually  dark  brownish -red  from  altered  blood, 
the  walls  villous,  the  cavity  pervaded  by  muscular  trabeculse.  In 
these  cases  a  softening  of  the  walls  appears  to  have  introduced  the 
enlargement  of  the  cystic  lymph  spaces." 

"  Bloodvessels  of  a  venous  character,  in  a  state  of  ectasis,^  are  very 
frequently  found,  as  already  mentioned  above,  in  the  vicinity  of  the 
myomata,  and  contribute,  in  the  extra-mural  forms,  not  a  little  to  the 
loosening  of  the  connection  between  the  tumor  and  the  uterine  tissue. 
Here  those  bleedings  characteristic  of  the  sub-mucous  forms  most  fre- 
quently originate  ;  partial  separations  of  the  surface,  thinned  by  the 
traction  of  the  tumor,  ensue,  opening  the  vessels.  In  this  latter  case, 
dilatation  of  .the  bloodvessels  takes  place  partly  in  a  passive  manner, 
while  the  development  of  ectases  of  the  bloodvessels  within  the  tissue 
of  the  tumor  is  of  a  decidedly  active  character,  their  formation  being 
probably  already  laid  in  the  origin  of  the  tumor.     Virchow  discrimi- 

1  jxTaa-if,  a  strcitcluiig  out. 


FIBROUS    GROWTHS    OF    THE    HTERUS.  517 

nates  this  form  properly  as  teleangiectatic^  or  cavernous  myoma 
(myoma  teleangiectases  sen  cavernosum).  Their  structure  corre- 
sponds completely  to  that  of  the  compound  fibro-myomata,  but  the 
muscular  substance  preponderates,  whilst  the  connective  tissue  portion 
diminishes.  The  large  muscular  cells  arranged  together  in  bundles, 
immediately  touch  the  vascular  walls,  which  consist  of  a  single  layer 
of  very  large  and  readily  detached  spindle-shaped  endothelium  cells. 
In  those  places  in  which  this  development  has  advanced  furthest,  the 
tissue  is  completely  like  the  erectile  tissue  of  the  corpora  cavernosa, 
only  narrow  partition  walls  separating  the  large  blood  sinuses  from 
one  another;  likewise  we  see,  on  longitudinal  section,  smooth-walled 
dilated  vessels  which  lead  to  the  wide  vascular  sinuses  in  the  periphery 
of  the  nodules  of  the  tumors.  The  cavernous  spaces  within  the  nodules 
I  might  designate,  on  account  of  their  structure,  as  ectatic  capillaries. 
The  smooth  muscular  fibres  in  these  tumors  possess  a  considerable 
degree  of  contractility  ;  in  the  recently  hardened  preparations  we  see 
regular  flexions  of  the  bundles  in  the  transverse  direction,  occasioned 
by  the  hardening  process,  just  as  occur  in  similarly  treated  smooth 
muscular  tissue.  In  this  way  is  explained  the  often  very  quickly 
chanoi;ino;  fulness  of  the  bloodvessels,  and  the  increase  in  volume  that 
has  been  many  times  observed  in  these  tumors,  reaching  sometimes, 
according  to  Kiwisch,  to  double  the  size  of  the  womb.  From  this 
must  be  discriminated  the  slower  increase  or  diminution  in  size  of  the 
organ,  Avhich  depends  on  the  filling  of  the  split-like  lymph  spaces, 
especially  in  the  vicinity  of  the  teleangiectatic  myomata." 

I  have  quoted  at  length  from  this  author,  since  he  presents  the 
latest  authority  on  this  subject,  and  I  have  nothing  to  offer  of  my 
own  on  the  early  development  of  these  tumors. 

Fibrous  growths  of  the  uterus  are  of  themselves  innoxious,  but, 
as  a  rule,  they  cause  great  mechanical  disturbance  from  bulk  and 
weight.  Therefore,  hemorrhage  with  menstrual  derangement  from 
obstructed  circulation  will  be  one  of  the  earliest  symptoms.  With  in- 
creased growth  there  occur  certain  displacements  of  the  uterus,  due 
chiefly  to  retroversion  and  prolapse.  Tlie  healthy  action  of  the 
bladder  and  rectum  becomes  impaired  at  an  early  stage,  as  a  conse- 
quence of  pressure,  from  which  great  suffering  is  caused  by  irritation 
of  the  bladder,  constipation  of  the  bevels,  and  the  formation  of 
hemorrhoids.      Moreover,  if  the  tumor  remains  wedged  within  the 

1  T6X(jf  'ayj-sTav  'iKs-Teiri^,  bloodvessels  stretcliiiig  out  (expansion  of  terminal  blood- 
vessels). 


518 


DESCRIPTION,   ETIOLOGY,   AND    DIAGNOSIS    OF 


Fig.  94. 


.y^" 


pelvis,  the  continuefl  pressure  on  the  nerves  and  bloodvessels  con- 
nected with  the  lower  extremities  leads  often  to  great  suffering  and 
serious  consequences  from  the  obstructed  circulation.  Should  the 
tumor  continue  to  grow  and  occupy  the  abdominal  cavity,  death  must 
ultimately  result  from  exhaustion.  Anaemia  is  early  caused  by  the 
continued  loss  of  blood,  while  the  state  of  exhaustion  is  at  length 
completed  by  the  functional  disturbance  due  to  continued  pressure  on 
the  stomach,  lungs,  heart,  and  kidneys. 

1st.  A  tumor  or  a  series  of  tumors  may,  by  increasing  bulk,  involve 
the  whole  uterus  in  every  direction  with  the  consequences  just  de- 
scribed. 

2d.  The  growth  may  become  developed  towards  the  outer  surface 
of  the  organ,  or  in  the  direction  of  the  uterine  canal.  If  on  the  outer 
surface,  it  would  be  termed  a  sub-peritoneal  fibroid.  As  such  it  may- 
remain  partially  protruding  from  the  uterine  wall,  or  it  may  become 

entirely  expelled  so  that  its  con- 
nection with  the  uterus  would  only 
consist  of  the  peritoneal  covering 
and  a  little  connective  tissue.  This 
would  form  a  pedunculated  sub-peri- 
toneal fibroid,  with  but  little  vitality 
since  its  source  of  nutrition  will  have 
been  nearly  cut  off.  It  may  thus 
remain  and  gradually  undergo  some 
degeneration.  The  weight  of  such 
a  tumor  as  shown  in  Fig.  94,  near 
the  fundus,  may  gradually  cause  the 
connection  with  the  uterus  to  be 
stretched  out  into  so  thin  a  pedicle, 
that  the  mass  may  become  at  some 
time  separated,  as  the  result  of  vio- 
lence. Peritonitis  and  its  conse. 
quences  Avould,  of  course,  result  from 
the  presence  of  the  detached  tumor  now  causing  irritation  like  a  foreign 
body.  The  mass  may  become  encysted  in  the  pelvis,  and  eventually 
be  destroyed  in  an  abscess  from  cellulitis,  or  it  may  form  new  attach- 
ments and  receive  a  sufficient  supply  of  blood  to  enable  it  to  con- 
tinue to  grow. 

A  sub-raucous  fibroid  may  gradually  be  forced  out  from  the  uterine 
tissue  into  the  canal  as  has  been  shown  to  take  place  under  the 
peritoneum.     This  is  accomplished  by  contraction  of  the  uterine  tissue 


\ 


Interstitial  and  sub-peritoneal  fibr  uds. 


FIBROUS    GROWTHS    OF    THE    UTERUS.  519 

by  which  the  tumor  is  driven  in  the  direction  offering  the  least  resist- 
ance. As  the  growth  advances  into  the  canal,  it  will  receive  a 
covering  of  the  mucous  membrane  over  the  projecting  portion.  When 
favorably  situated  the  tumor  becomes  pedunculated,  and  is  then  termed 
a  polypus. 

It  has  been  generally  taught  that  each  tumor  is  invested  with  a 
distinct  capsule.  This  is  a  most  important  point,  and  from  its  bearing 
in  practice  should  be  definitely  settled.  "While  it  is  not  my  province 
to  make  issue  ■with  the  pathologist,  since  I  cannot  substantiate  my 
impressions  from  actual  study  of  the  minute  tissues,  my  observation 
in  many  cases  leads  me  to  question  the  existence  of  such  a  cover- 
ing. When  a  fibrous  tumor  is  grooving  rapidly,  it  certainly  cannot  be 
then  invested,  or  isolated,  as  it  were,  by  a  capsule.  Such  an  arrange- 
ment could  only  be  conceived  of  after  a  tumor  had  ceased  to  grow. 
As  a  fibrous  tumor  grows,  it  seems  to  incorporate  the  uterine  tissue  in 
advance  of  the  actual  limit  of  the  tumor,  Avithout  producing  at  first  a 
marked  change  in  structure,  as  a  drop  of  water  would  do  on  a  lump  of 
sugar,  permeating  the  mass  before  effecting  the  solution  of  each  suc- 
cessive portion.  Experience  has  taught  me  that  a  fibrous  tumor, 
while  still  increasing  in  size,  cannot  be  enucleated  as  from  a  capsule. 
It  may  be  torn  out  by  force  from  the  uterine  tissue,  but  it  will  be 
done  at  the  expense  of  its  integrity,  since  portions  of  the  tumor  will 
be  left  adherent  to  the  uterus,  and  healthy  uterine  tissue  will  be  found 
on  the  ragged  surface  of  the  tumor.  When  a  fibroid  has  ceased  to 
grow,  and  has  been  long  subjected  to  compression  by  uterine  con- 
tractions, it  can  be  shelled  out  of  its  bed  with  the  greatest  facility,  and 
with  a  smooth  surface  as  from  a  capsule.  But  the  tumor  has  not  in 
reality  acquired  a  distinct  membranous  investment,  the  enucleation 
being  determined  simply  by  a  difference  in  the  degree  of  density  of 
tissue  between  the  hard  fibroid  and  the  uterine  structure.  After  mace- 
rating a  hard  fibroid  I  have  succeeded  in  separating  portions  of  four  and 
five  distinct  investments,  like  the  concentric  layers  of  an  onion,  each 
layer  being  thinner  and  thinner  from  without  inward,  until  the  last  and 
innermost  becomes  blended  with  the  true  fibrous  structure.  At  the 
Woman's  Hospital,  I  once  accidentally  enucleated  a  fibroid  from  its 
outer  covering.  This  was  afterwards  separated  from  the  uterine 
tissue  with  difficulty,  and  was  supposed  at  the  time  to  be  the  thick 
walls  of  a  cyst. 

3d.  If  the  tumor  remains  interstitial  it  will  receive  a  much  smaller 
supply  of  blood  than  if  it  were  situated  under  the  mucous  membrane. 
It  frequently  then  remains  passive,  and  from  being  subjected  to  long 


520  DESCRIPTIOX,   ETIOLOGY,   AND    DIAGNOSIS    OF 

and  continued  pressure  by  uterine  contraction,  it  at  length  becomes 
exceedingly  dense  in  structure,  with  the  not  uncommon  result  of 
finally  undergoing  calcareous  degeneration.  This  structural  change 
has  been  compared  to  a  coral  formation  Avith  minute  interstices,  as  in 
the  spongy  portion  of  bone.  It  is  a  degeneration  of  the  tissue  proper, 
leaving  the  few  bloodvessels  unchanged  in  their  course  through  the 
porous  portion.  These  masses  are  sometimes  expelled  from  the  uterus, 
and  are  mentioned  by  the  early  writers  who  were,  however,  ignorant  of 
their  mode  of  formation.  I  have  found  this  degeneration  in  the  midst 
of  a  second  growth,  showing  that  the  first  had  ceased  and  undergone 
this  degeneration,  but  became  afterwards  involved  and  embedded  in 
the  advance  of  a  second  tumor  which  had  an  entirely  difi'erent  origin. 

The  uterus  sometimes  disintegrates,  as  it  were,  into  many  distinct 
tumors,  as  I  have  had  occasion  to  observe.  While  in  charge  of  the 
Woman's  Hospital,  some  ten  years  ago,  a  woman  was  brought  to  the 
institution,  suffering  from  an  immense  fibrous  tumor,  and  in  so  ex- 
hausted a  condition  that  in  charity  she  was  admitted.  For  several 
years  she  had  been  free  from  hemorrhages,  and  the  tumor  had  appai'- 
ently  increased  but  little  in  size  during  the  same  time.  But  from  the 
effects  of  long  pressure  and  from  the  great  weight  of  the  mass  she  had 
suffered  continually.  For  her  permanent  relief  there  was  nothing  to 
be  done,  since  she  was  in  too  exhausted  a  condition  to  attempt  the  re- 
moval of  the  uterus,  if  this  operation  had  been  thought  advisable. 
She  was  emaciated  to  a  remarkable  degree,  so  much  so  that  the  tumor 
really  constituted  the  greater  portion  of  her  body.  She  died  from 
exhaustion  a  few  days  after  admission,  every  function  having  long  been 
obstructed  in  its  healthy  action. 

After  opening  the  abdomen  the  tumor  was  found  to  be  literally  a 
conglomerated  mass  held  together  apparently  by  a  thin  capsule  over 
all,  through  which  the  inequalities  could  be  seen  and  felt,  while  through 
the  abdominal  wall  the  tumor  seemed  to  be  solid.  The  uterus  was 
laid  open  Avith  great  difficulty  and  in  section  presented  very  much  the 
appearance  represented  in  Fig.  95.  The  whole  uterine  tissue  had 
become  converted  into  hundreds  of  fibroids  of  all  sizes,  with  but 
little  or  no  connective  tissue  between  them.  These  gi'owths  had  gone 
on  until  at  length  the  bloodvessels  in  the  interior  had  become  oblite- 
rated by  pressure,  and  only  those  masses  forming  the  outer  portion 
could  have  received  any  nutriment  through  the  circulation.  They  had 
in  fact  become  foreign  bodies.  Within  the  mass  several  tumors  were 
found  to  have  undergone  calcareous  degeneration,  as  represented  in 
the  figure.     Subsequently  a  somewhat  similar  case,  but  of  less  size, 


FIBROUS    GROWTHS    OF    THE    UTERUS 


621 


died  at  the  Woman's  Hospital  in  the  service  of  eitlier  Dr.  Sims  or 
Dr.  Peaslee. 

4th.    Fibrous   tumors  sometimes   undergo    disintegration  and   ab- 
sorption.    As  the  effect  of  direct  injury,  or  in  connection  with  the 


Fiv.  95. 


Multiple  fibroids. 

puerperal  state,  the  mass  may  after  sloughing  undergo  purulent  disin- 
tegration, and  this  process  is  almost  always  complicated  by  symptoms 
of  blood-poisoning.  These  tumors  are  also  occasionally  absorbed  and 
rapidly  disappear  after  having  reached  a  point  of  development  at  Avhich 
their  supply  of  blood  seems  to  be  cut  off. 

Case  XXVII. — I  had  a  woman  several  years  under  my  observation 
who  was  a  seamstress  in  my  employ  during  the  greater  part  of  the 
time.  She  had  a  well-defined  fibroid  on  the  anterior  wall  of  the 
uterus,  as  large  as  a  hen's  egg,  which  caused  much  irritation  of  the 
bladder,  and  she  suffered  in  addition  from  constant  hemorrha-J-es.  I 
treated  her  for  some  six  months  without  any  benefit,  in  fact  the  o-rowth 
increased  in  size.  Some  eighteen  months  afterwards  she  informed  me 
that  she  had  gone  several  weeks  without  a  show,  and  had  just  passed 
through  a  natural  period.  On  making  an  examination  I  was  surprised 
to  find  the  tumor  had  greatly  decreased  in  size,  and  in  two  months 
from  that  time,  the  uterus  was  of  a  normal  size,  with  not  the  slightest 
vestige  of  the  fibroid  remaining.  The  tumor  from  some  cause  had 
probably  undergone  fatty  degeneration,  and  was  absorbed. 


522  DESCRIPTION,   ETIOLOGY,    AND    DIAGNOSIS    OF 

I  have  had  three  women  under  observation,  each  with  a  fibroid  on 
the  anterior  wall,  which  disappeared  during  a  subsequent  pregnancy. 
One  of  these  was  a  ladj  of  Avealth  and  position,  residing  in  Brook- 
lyn, and  in  consequence  of  an  absorption  of  the  fibroid,  I  suffered 
in  reputation  among  a  large  circle  of  her  family  connections. 

Case  XXVIII. — This  lady  had  been  married  a  number  of  years 
and  had  been  sterile  and  irregular.  I  was  called  to  see  her  in  conse- 
quence of  her  suffering  from  great  pressure  on  the  rectum,  which  had 
been  increasing,  and  at  length  had  become  complicated  with  retention 
of  urine.  I  found  the  uterus  completely  retro  verted,  with  the  cervix 
behind  the  symphysis,  and  containing  a  foetus  at  about  the  third 
month  of  development.  Above  the  pubes  was  found  a  sub-peritoneal 
fibroid  in  the  anterior  wall  of  the  uterus,  just  above  the  vaginal  junc- 
tion. This  could  be  felt  through  the  abdominal  parietes,  and  was 
almost  as  prominent  and  well-defined  as  a  door  knob  would  be  when 
in  the  grasp  of  the  hand.  After  emptying  the  bladder,  she  was 
placed  on  her  knees  and  elbows,  and  in  her  nightgown,  that  the  ab- 
dominal walls  might  be  perfectly  relaxed.  I  was  then  able,  by  pres- 
sure from  the  rectum  and  by  aid  of  the  force  of  gravity,  and  the 
leverage  exerted  by  means  of  this  fibroid,  to  lift  the  uterus  out  of  the 
pelvis,  so  that  the  cervix  was  made  to  occupy  the  position  in  which 
the  fundus  was  before  the  operation.  When  this  had  been  accom- 
plished, the  uterus  was  crowded  back  against  the  promontory  of  the 
sacrum,  as  the  fibroid  rested  behind  the  pubes.  The  relief  was  perfect, 
but  it  was  evidently  a  question  of  importance  to  determine  without 
delay  if  she  could  go  and  be  delivered  at  full  term  with  safety.  This 
I  did  not  consider  myself  competent  to  decide,  and  called  the  late 
Dr.  George  T.  Elliott  into  consultation.  The  doctor  made  several 
careful  examinations,  and  ascertained  accurately,  by  measurement, 
the  pelvic  diameters,  with  the  conclusion  that  she  should  go  to  full 
term.  I  placed  her  in  his  charge,  and  at  my  request  she  left  home 
and  took  a  furnished  house  in  his  neighborhood,  that  she  might  have 
every  advantage.  Dr.  Elliott  saw  her  frequently  during  the  course 
of  her  pregnancy,  in  relation  to  her  general  condition,  but  did  not,  I 
believe,  make  an  examination  after  the  fifth  month.  As  often,  and 
very  provokingly,  happens  under  such  circumstances.  Dr.  Elliott  Avas 
unexpectedly  detained  by  some  case  seen  in  consultation  out  of  town 
at  the  time  when  labor  came  on,  and  the  husband  in  his  anxiety  for 
her  condition  called  in  the  late  Dr.  Budd  to  attend  her.  The  labor 
was  a  remarkably  easy  one,  and  Dr.  Budd,  knowing  nothing  of  the 
history  of  the  case,  and  finding  no  tumor,  expressed  his  doubt  if  one 
had  ever  existed.  Dr.  Elliott  and  myself  simply  had  the  opportunity 
of  verifying  Dr.  Budd's  statement  that  she  had  no  tumor  at  that  time, 
but  we  were  denounced  for  our  ignorance,  and  for  the  anxiety  we  had 
caused. 

The  second  case  was  a  patient  in  the  Woman's  Hospital  under  the 
charge  of  Dr.  R.  C.  M.  Page,  while  he  was  house  surgeon  in  that 


FIBROUS    GROWTHS    OF    THE    L'TERUS.  523 

institution.  I  examined  the  woman  frequently  during  her  stay  in  the 
hospital.  She  subsequently  became  pregnant,  and  after  her  delivery 
it  was  found  that  the  tumor  had  disappeared.  This  fact  I  verified  by 
an  examination,  and  the  woman  has  remained  for  several  years  under 
Dr.  Page's  observation  without  a  return  of  the  growth. 

The  other  instance  was  in  my  private  practice,  and  was  seen  only 
by  myself.  The  tumor  was  much  smaller  than  in  either  of  the  other 
cases,  but  the  fact  was  as  well  settled  in  my  mind  as  to  its  disappear- 
ance during  her  pregnancy. 

Fibroids  occasionally  become  the  seat  of  sarcomatous  and  carcino- 
matous growths.  I  have  had  several  instances  under  observation 
where  the  tissue  of  a  single  fibroid  rapidly  underwent  the  metamor- 
phosis into  sarcoma.  Klebs  makes  the  following  statement  in  regard 
to  these  growths,  and  in  direct  connection  with  what  has  just  been 
quoted  from  his  work  on  the  development  of  fibroids.  "  With  these 
hyperplastic  new  formations,  heteroplastic  ones  become  associated,  of 
which,  within  the  fibro-myomaia  of  the  uterus,  myxomatous  and  sar- 
comatous developments  occur.  Epithelial  formations  are  completely 
wanting,  and  genuine  carcinomata  can  thence  only  proceed  out  of 
fibro-rayomata  in  those  cases  in  which  the  formation  of  the  tumor  ex- 
tends to  the  surface  of  the  mucous  membrane." 

"  The  growing  of  the  carcinoma  into  the  myoma  happens  in  the  same 
way  as  the  penetration  would  take  place  into  the  normal  uterine 
muscular  tissue,  continuously  or  discontinuously.  The  development  of 
myxomatous  and  sarcomatous  tissue  proceeds  from  the  neighborhood 
of  the  vessels,  and  embraces  usually  only  particular  parts  of  the  tumor, 
which  in  the  one  case  undergo  a  gelatinous  softening,  and  in  another 
are  transformed  into  a  whitish-gray  fibrous  tissue.  The  latter  espe- 
cially proliferates  extensively,  and  leads  thereby  to  considerable  en- 
largement of  the  tumor,  mostly  one-sided."  We  Avill  have  again  to 
refer  to  this  subject  Avhen  treating  of  the  forms  of  malignant  disease. 

It  is  not  impossible  that  an  aneurism  may  be  developed  in  or  upon 
a  fibrous  tumor  of  the  uterus,  by  dilatation  of  one  or  more  of  its  prin- 
cipal vessels.  Its  existence  would  be  indicated  by  the  aneurismal 
purr  or  thrill  in  the  site  of  the  tumor.  The  diagnosis  must  often  be 
very  obscure,  and  the  treatment,  where  the  tumor  is  so  located  as  to 
render  its  removal  or  the  application  of  a  ligature  impossible,  neces- 
sarily involves  ablation  of  the  uterus  and  appendages.  The  cure  by 
continued  pressure  is  not  to  be  hoped  for.  A  very  interesting  case  of 
supposed  aneurism  complicating  fibroid  occurred  in  the  practice  of 
Dr.  E.  D.  For^e,  of  Louisville,  Kentucky.     There  was  a  dift'erence 


524  DESCRIPTIOX,   ETIOLOGY,   AND    DIAGXOSIS    OF 

of  opinion  as  to  the  diagnosis,  but  an  operation  was  decided  upon, 
and  the  lady  died  upon  the  table.  A  dissection  of  the  tumor  after- 
wards failed  to  reveal  whether  there  was  a  true  aneurismal  sac,  or 
only  a  cyst  to  which  the  pulsation  and  purr  had  been  imparted  from 
neic^hborin;^;  vessels. 

JEtiology  of  Uterine  Fibrous  G-rowtJis. — The  statistical  history  and 
the  data  which  the  general  study  of  menstruation  presents  furnish  no 
evidence  that  fibrous  growths  ever  exist  at  puberty.  Fibrous  tumors 
rarely  make  their  appearance  before  the  age  of  twenty-five  in  the 
unmarried,  at  a  later  age  in  the  sterile,  and  at  a  much  more  advanced 
one  with  fruitful  women.  It  is  impossible  to  determine  with  accu- 
racy the  age  at  which  these  groAvths  are  most  likely  to  appear,  since 
their  development  is,  as  a  rule,  slow  at  first,  and  they  may  exist  for 
an  indefinite  period  before  their  presence  is  recognized.  The  age  can 
only  be  approximately  inferred  from  the  average  one  at  which  pro- 
fessional advice  was  first  sought,  and  this  would  seldom  be  before  the 
tumor  had  reached  a  suificient  size  to  cause  hemorrhage  or  some  other 
disturbance.  We  may  also  gain  some  information  as  to  the  rapidity 
of  growth  from  the  length  of  time  elapsing  after  the  birth  of  the  last 
child,  for  a  fibroid,  it  is  well  knoAvn,  is  a  cause  of  sterility.  In  Table 
XL.  is  shown  the  age  at  which  225  women,  who  had  fibrous  growths, 
were  first  examined.  The  earliest  age  was  at  18,  an  unmarried 
woman;  the  next,  a  sterile  woman,  at  the  age  of  22  ;  1  at  23  ;  10 
between  the  ages  of  21  and  25  :  and  1  at  the  advanced  age  of  58. 

The  age  of  greatest  liability  to  fibrous  growths,  for  all  women,  is 
shown  to  be  between  30  and  35  years.  But  if  we  limit  the  considera- 
tion to  those  only  who  had  fibroids  and  fibrous  tumors,  we  find  85.26 
years  as  the  average  age  for  the  first,  and  38.01  years  for  the  latter 
(see  Table  XLI.).  It  would  be  natural  to  expect  a  sterile  woman  to 
seek  advice  at  an  earlier  age,  for  the  relief  of  her  sterile  condition, 
and  this  would  afford  the  opportunity  for  the  earlier  recognition  of 
the  growth.  But  it  is  also  probable  that  an  increase  in  the  size  of 
the  abdomen  from  a  fibrous  tumor  would  at  first  be  mistaken  by  the 
sterile  as  Avell  as  the  fruitful  women  for  pregnancy,  and  so  the 
examination  would  be  delayed  ;  but  not  so  with  the  unmarried  woman, 
for  she  would  naturally  seek  an  early  explanation. 

The  development  of  these  growths  is  retarded  by  childbearing,  and 
even  by  marriage,  for  the  sterile  woman  is  less  liable  than  the  old 
maid,  but  in  turn  she  is  more  so  tlian  the  woman  who  has  borne 
children.  If  we  accept  as  the  proper  one  the  relative  proportion  of 
unmarried,  sterile,  and  fiuitl'ul  to  each  other  given  in  Table   III., 


FIBROUS   GROWTHS    OF    THE    UTERUS. 


525 


under  tlie  head  of  menstruation,  it  will  be  seen  that  unmarried  women 
are  the  least  liable  to  fibroids,  the  sterile  much  more  so  (note  here 
the  effect  of  fibroids  in  causing  sterility),  while  only  a  small  propor- 
tion of  fruitful  women  suffer  from  them. 

Table  XL — ^if/es  at  which  225   Women  with  Fibrous  Growths  xoere 

first  examined. 


Age  at  first  consuliation  . . 

15 
to 

20 

20 
to 
25 

23 
to 

.30 

30 
to 
35 

35 
to 
40 

40 
to 
45 

45 
to 
fiO 

50 
to 
55 

do 
to 

60 

1 

;  Total. 

x       f  Unmarried 

.■2       1  Sterile 

2     <!  Fruitful 

^       L            Total 

. . . .    ■       2 
....          3 

2 
9 
4 

4 
11 
19 

6 
IS 

4 
3 
12 

"3' 

7 

2 

1 

:::: 

20     • 
37     ! 
62     ] 

15 

34 

" 

19 

10 

3 

ll'J 

1 

2 

1 

2 
3 
3 

7 

7 

10 

4 
2 
5 

3 
11 

7 

5 

"'s' 

1 
2 

1 

'3' 

1- 

!     26 
1     37 

=  £     Sterile 

2  S-(  Fruitful 

'^^\.            Total 

1 

' 

s 

21 

11 

21 

13 

4 

3 

1     88 

1 

rUomarried 

o  X     Sterile 

%'t-l  Fruitful 

L           Total 

.... 

1 

"W 

.... 

1 
5 

1 

"i' 

"2' 

"i' 

2 

2     ' 

2     1 

u    1 

.... 

2 

2 

' 

6 

2 

2 

1 

2 

18 

f  Unmarried 

X        Sterile 

S         Fruitful 

g                    Total 

m         Percentage  for  each 
L     period 

1 

:::: 

4 
5 
3 

4 

12 
9 

29 

11 
9 

28 

8 
14 
20 

5 
3 

17 

3 
3 

2 

5 

47 

65 

113 

1 

•44 

12 

5-33 

25 

II. II 

ao 

26.17 

48 
21-33 

42 

18.62 

25 

II. II 

8 
3-55 

5 

2.22 

225 

Table  XLI — Average  Ages  at  first  consultation  of  those  who  had 
Fibroids  and  Fibrous  Tumors. 


Fibroids. 

Average  age. 

Fibrous  tumors. 

Average  age. 

Unmarried 

Sterile 

Fruitful 

On  all  M-omen  .... 

37.55 
33.46 
35.64 
35.26 

Unmarried 

Sterile 

Fruitful 

On  all  ■women  .... 

35.75 
37.51 
40.28 
38.04 

Table  XLII.  shows  that  of  all  women  with  fibroids  13.37  per  cent, 
were  unmarried,  and  50.30  per  cent,  were  fruitful.  Both  of  these 
classes  of  women  are  thus  shown  to  be  about  four  per  cent,  less  liable 
to  these  growths  than  their  relative  proportion  in  the  total  number  of 


526  DESCRIPTION,    ETIOLOGY,    AND    DIAGNOSIS    OF 


S 

[ 

I— I 


i 

i| 

, 

1 

I 

— 

ac  ooor- 

CC 

'0«  oo 

o 

j              ?«  9S« 

i .  i~-  *d  3  r; 

O 

O  w  iC  c^ 

ix; 

CO  o       o 

o 

l|SJc4lN  so 

sq 

'"' 

r-itN         I-l 

l-t 

?!         ,Otr-00 

r^ 

—  O  O  N 

ei 

=  CC  c  o 

O 

00 

T?               ,       COC^ 

-^ 

t— 

■ — 

OO         O 

C4 

.     «o 

« 

~^  -*i  -*  ^ 

-** 

-^--j"  rj^ 

-^ 

■* 

i  .^ 

--41 

1       sSwaAY 

^r-ii-(« 

i-l         ,    r^i-  .-— . 

'^ 

rl  .-.  ".  1-1 

'~' 

|rt  r-i-lr^ 

■"■ 

" 

■"■ 

1      'aSBanao 

.... 

1               --ia<I 

:  :r|    :  :  :  : 

■•^ 

1  :  :  :  : 

:    '     : 

o 

1 

-i 

-  :  i  :  :  :  : 

^  : 

t^ 

.... 

o 

....    1  ^      ,     o 

t- 

o 

M  . ||  .  .  .  - 

"^  : 

' 

N 

!  ^ 

o 

CJ 

; 

ooi 

lO 

—  o  ^ 

.      .      .  — 

,    c-^         .      ,      .  ^ 

.  I-" 

...  a: 

.  c 

j    .     .     .  Cq 

.    C 

.     •     .  r^ 

c^ 

OO    f 

O  ~  " 

.      .      •            1        •    ^          •      •      ■ 

•  t^ 

•  CC 

*  ^       •"• 

d 

1— «       M 

>> 

:S 

.    .1 

o 

E 

•       •  d      • 

-  'C',|  •   •«  • 

.  a 

1   .    .jq    . 

.     .  I-l     . 

.  c 

■    .       n 

CO  q 

S 

'^'r 

:  : 

:  o,   :  :     : 

•""•1 

•  ^ 

•  ^ 



1 

m 

••> 

.  CO  ! 

K  1 

c> 

.  c 

VI 

o 

o  S 

;^    ;   ; 

*  ci ;    -  c^   •   • 

'■  aI 

:^'i  :  : 

•  ^ 

:^  :  '. 

;«    ;    ; 

•Nil     ^ 

VO 

00    ^ 

^ 

IT.     >       . 

-i 

1/1 

"-' 

•    *. 

111 

lO 

.  ^.  ! 

.00  1 

r^- 

^n 

„ 

en 

—   — 

t^   .    .    . 

•   ^'     o     •     •     • 

N  •  •  • 

.   1/1 

.  c 

-^    .    .    . 

m  OO 

o 

t-  <? 

—  o 

*  r'.    :^^    ■     •    • 

•  u-.| 

"  u". 

<N 

-<•    Cv 

f.                 •     • 

" 

•    Ci 

" 

.    .    .    .  1     .    ■          ... 

n| 

.J 

o 

o 

Ct 

IM   irv| 

«    Ov 

^ 

-^! 

"" 

" 

" 

....  1 

., 

1 

•1 

VO 

t~ 

cc 

•    •        .  f— e    .    . 

^  t^ 

I  .1-1  •  ' 

« 

ei  ". 

" 

.... 

:  :  1  :      :  : 

" 

i  :     :  : 

'■ 

It 

r.    \ 

CN 

' 

00 

i  ■ 

„ 

t^^ 

Ov 

00 

t^ 

.  jq    .    . 

O     t^ 

^  N  .  • 

yi  ^- 

.  r-<       •       • 

.—     2 

*i    .    .    . 

N   "O 

O 

lO 

n  « 

*"" 

<=■  1 ,     :  ; 

CC 

VC 

.        .    . 

^ 

N 

t^ 

"-•oo 

--  : 

cc 

- 

1           .    . 

- 

OD 

in 

o 

ir:' 

n .-    -i-i 

t*   '' 

^•S      -11 

--   "^ 

sqj^    •    • 

-^1    w 

•!—(•> 

■-I    ^ 

CO 

w 

i^  ** 

" 

-il 

M 

r-1     fT-, 

!      •  '■ 

« 

* 

■^ 

o 

<M    p. 

-      1                      . 

^ 

' 

^ 

0 

t^ 

l-N 

„ 

*^ 

.  *i  —    . 

:c   -    |=co    .-H 

o   "^ 

^^  :o     •    • 

'      •  7i       '  l-t 

CC    = 

•  r-      •  1— 1 

«    •? 

04 

It 

■O    ov 

" 

•—    c^ 

i         :  : 

- 

s 

ex3 

'"' 

M 

p"-  1 

., 

CO 

0 

1 

00 

„ 

m 

-f 

N«=    -   • 

t*        •.•       '  ^     in    1—     !— 

»  "C 

-i<c~^(M 

Uor-lr-l 

Qo  q 

't— 1      •      >      • 

rH    ^ 

m 

I-l 

CO   ov 

*"* 

c 

*~*  o 

1 

? 

Oi 

c» 

CO    c4 

oo 

„ 

o 

' 

03 

in 

2" 

M    *^ 

(MOO—  « 

i  n 

t— ■ 

■<s- 

!-  O 

— 

^ 

■.^ 

1—" 

VO 

«  Ov 

■^ 

" 

1 

" 

" 

"  ! 

^  1 

CC 

o 

.   .  1 

CJi 

„ 

M  m 

rHDI      .     - 

.      .          CO 

" 

^ 

- 

1     ■ 

VO 

t-l 

,  .   .   .   . 

:  :| 

t~ 

I-l  OO 

VO   i: 

2 

.... 

VO 

.* 

T^  >n 

^    i                   •      • 

f*". 

. 

^ 

•  •  1 

^ 

c< 

'     .      .      .      . 

.  .11    . 

p. 

'^ 

CO 

■  ■ 

X       *       '       * 

y 

X 11      • 

—     .     .     , 

a    .    .    .       .    . 

o 

1 

:  :  :  :      :  c     :  .  :  • 

3 

=    ■   •   • 

a    .    . 

:=    g 

1 

tf 

:  o    ;    .    .        .  M 

•  tc     a 

•  •  •  •      ■  —  j  •  »  •  . 

c 

•     .     . 

•  e 

?N-        •        •        •                 '3 

1*-    .   . 

•  alia 

.—  o 

o    •    •    •       ^  C 

o    •    • 

—  So 

■^  -t  ■     -••"•"■  "tf  : 

s  ?■ 

cS  g 

=s£.  a 

a 
o 

Jiifi   ^;5   -m% 

^1 

'  =  =.^-? 

ii5?  h;2 

s.=  5?   ^^  fe 

• 

^ 

-^.'2             '  =  5  =  = 

'  p-  c  c  o 

a  o  o  o 

l££^c2                 |3^ 

3 

2^  i:-!  1- 

«cafr«E-i 

"3 

^ 

^                                   , 

a  s 

c  ® 

V 

-~                            ^   — 

C3 

oi 

""s"^ 

-  o 

■"-a 

~  C  "7  t 

Im 

oi 

a 
2 

a 
o 

2 

C    S    S;~ 

>^  tr.   Up  r 

=  S  i-  £  d 

'= 

O    -   5 

c:  'i: 

o  2-s  Sr     ' 

Is 

i^a. 

e 

c-S        '       ^Zi 

-  *'  a  C 

^  u 

ac:  c~  5 

5  -^  >  —  X 

E 

o 

I 

fill 

v^ 

—  •-  a  —  = 
a.^-awTS 

—  P  S  o  2 

=   OS 

_  a 
5- 

3 

a 
"3 

X.S—   §) 

w.  r  —  ■"  .a         o  "• 

o 

u_ 

! 

' 

■^c 

s   ■** 

H 

FIBROUS    GROWTHS    OF    TUE    UTERUS, 


527 


pa 


•oSnu-imn }« 


•eS'Biuoojaj 


•Xiunirang 


^ 


(jq       M       Tfi  t^ 


•rV  (M  t- 


CO         C^         ^ 


CO         CO         o 


'^  CI  00 


Tfl  -t  '^ 


CO         CO         o 


D      rn 


cu 


aq;  ui 
punoj  sjouin;  snojqij 


528  DESCRIPTION,   ETIOLOGY,   AND    DIAGNOSIS    OF 

all  women  under  observation.     But  sterile  women  are  shown  in  the 
table  to  be  about  ten  per  cent,  more  liable. 

It  has  been  already  stated  that  any  distinction  drawn  between  a 
fibroid  and  a  fibrous  tumor  is  a  conventional  one.  For  convenience 
it  is  accepted  that  fibroids  become  fibrous  tumors  as  they  increase  in 
size,  but  we  cannot  designate  the  exact  stage  at  which  one  term 
would  be  applicable  and  the  other  not  so.  But  when  these  growths 
become  so  large  that  they  can  no  longer  remain  in  the  pelvis,  they 
are  termed  fibrous  tumors. 

Table  XLIII.  is  made  up  of  cases  of  such  fibrous  tumors.  The 
most  important  point  presented  by  the  table  is  the  influence  which 
marriage  and  pregnancy  seem  to  have  on  such  growths.  Unmarried 
women  are  shown  to  have  a  liability  to  this  form  of  the  disease  about 
twice  as  great  as  their  general  ratio,  while  both  the  sterile  and  fruit- 
ful women  appear  to  be  below  their  general  average  in  liability — 
the  fruitful  to  the  extent  of  some  thirteen  per  cent. 

We  may  safely  hold  that  all  women  are  in  early  womanhood  liable 
in  about  the  same  degree  to  the  development  of  fibroids.  The  rate  of 
growth,  or  development,  however,  is  not  only  held  in  check  by  mar- 
riage and  child-bearing,  but  we  have  seen  that  these  growths  some- 
times disappear  during  or  after  pregnancy. 

Between  the  ages  of  thirty  and  forty  years  the  unmarried  woman  is 
fully  twice  as  subject  to  fibrous  tumors  as  the  sterile  or  the  fruitful. 
I  have  already  referred  to  this  subject,  when  treating  of  the  causes  of 
disease,  and  pointed  out  that  this  is  one  of  the  tributes  which  an  un- 
married woman  pays  for  her  celibacy.  It  seems  as  if  it  were  the 
purpose  of  nature  that  the  uterus  should  undergo  the  changes  depend- 
ent upon  pregnancy  and  lactation,  about  once  in  three  years  through- 
out the  child-bearing  period,  and  that  if  the  uterus  is  not  physiologi- 
cally occupied  in  child-bearing  a  fibroid  will  the  more  rapidly  develop 
into  a  fibrous  tumor  as  the  woman  advances  in  life.  This  will  also  be 
the  case  with  the  married  woman  who  has  taken  means  to  prevent 
conception,  as  well  as  with  her  who  has  been  sterile  from  some  cause 
beyond  her  control,  but  to  a  less  degree  in  the  latter  case.  I  think  I 
have  had  occasion  to  note  that  the  sterile  woman  who  has  earnestly 
wished  for  children  does-  not  have  her  liability  to  fibrous  tumor  in- 
creased by.  the  fact  of  her  sterility,  an  instance,  probably,  of  the  re- 
markable oflFect  of  mind  upon  the  body.  Finally  the  Avoman  who  may 
have  been  fruitful  in  early  life,  but  remained  sterile  long  afterwards, 
from  some  accidental  cause,  may  have  a  tumor  developed,  but  is  less 
liable  thereto  from  having  once  borne  a  child. 


FIBROUS    GROWTHS    OF    THE    UTERUS, 


529 


We  have  condensed  in  Table  XLIV.  the  facts  concerning  fibroids 
and  fibrous  tumors  which  are  contained  in  the  two  preceding  tables, 
showing  again  that  the  liability  of  unmarried  and  sterile  women  to 
these  growths  is  greater  than  their  relative  proportion  of  all  women 
under  observation,  while  it  is  less  with  women  who  have  been  im- 
pregnated. 

Taule  XLIV. —  Condensed  from  Tables  XLII  and  XLIII. 


n 

■z.  ^ 

26 
21 
3j 

Fibroids  situated 

in 

B 

a 

1/3 

0 
te 
a 

a 

(S 

Ph. 

0    . 

0  6 
It 

Front. 

Be- 
hind. 

On 

the 

right. 

On 
the 
left. 

a  2 
rt  a  o 

u-    3    - 
g  -^  —  J 

£  '2  rt 

7 
20 
20 

11 

28 
45 

2 
3 
3 

1 

6 

11 

47 

78 

114 

19.66 
32.63 
47.69 

14.29 
14.15 
14.42 

23.15 
21.20 

Fruitful 

Total    

82 
34-3° 

47 
19.66 

84 
35-14 

8 
3-34 

18 
7-53 

239 

14.30 

22.04 

We  will  find  in  Table  XLII.  the  average  age  at  puberty  and  at 
marriage  for  each  condition,  and  the  locality  of  the  fibroid  with  respect 
to  each  is  also  given,  but  I  cannot  attempt  to  make  any  definite  de- 
ductions therefrom. 

The  same  information  Avill  be  found,  in  Tables  XLIII.  and  XLIV., 
for  fibrous  tumors,  and  for  all  fibrous  growths.  In  Table  XLIV.  we 
find  the  average  age  at  marriage  for  the  sterile  woman  to  have  been 
23.15  years  ;  for  the  fruitful  woman  21.20  years;  while  the  average 
for  both  was  22.04  years.  We  have  here  a  practical  point  bearing 
upon  the  beneficial  efifect  of  marriage  in  limiting  the  liability  to  fibrous 
tumors.  For  nineteen  hundred  women  under  observation,  with  dif- 
ferent diseases,  the  average  age  at  marriage  was  22.31  years.  The 
average  for  all  women  who  had  been  impregnated  was  20.76  years, 
while  for  the  sterile  women  it  was  22.39  years  of  age.  It  is  thus 
shown  that  the  average  age  at  marriage  for  the  sterile  and  fruitful 
•who  sufi'ered  from  fibrous  growths,  was  much  later  than  the  general 
average. 

The  location  of  fibroids  in  the  uterine  walls  is  determined  by  some 

unknown  law,  yet  one  evidently  exists,  for  about  one-half  of  them  are 

found  on  the  posterior  wall.     Xext  in  frequency  they  are  found  in 

front;  then  on  the  left;  and  lastly  on  the  right  side.     As  a  fibroid  in- 

34 


530 


DESCRIPTION,    ETIOLOGY,    AND    DIAGNOSIS    OF 


creases  in  size,  and  becomes  a  fibrous  tumor,  it  "will  be,  as  a  rule,  ac- 
companied by  others,  and  at  length  they  all  become  so  much  incorpo- 
rated -with  the  uterus  as  to  render  it  impossible  to  fix  upon  any  special 
locality  for  them. 


Table  XLV Fibrous  Groicths  with  reference  to  Regularity  of 

Menstruation. 


Condition  of  menstruation  a:  Ptiberty. 


Unmarried.       Sterile.       Fruitful. 


-3 


Regular  from  fhe  first 
Percentage  . 


Regular  afterwards 
Percentage   . 


Never  regular     . 
Percentage 


17 
80.95 

4 
19.04 


33 
62.26 

12 
22.64 


15.09 


50 
75-75 

14 
21,21 

2 
3-03 


Total  .     . 
Percentage 


21 
15.00 


53 
37.85 


66 
47.14 


Total 

and 

per  cent. 


100 

71.14 

30 
21.42 

10 

7.14 


140 
64.S1 


Regular  from  the  first 
Percentacre   . 


Regular  afterwards 
Percentage  . 


Never  regular    . 
Percentage 


18 
72.00 

4 
16.00 

3 

12.00 


Total  .     . 
Percentage 


25 
32.89 


14 
70.00 


1 

5.00 


20 
26.31 


22 
70.96 

8 
25.80 


31 
40.78 


'Regular  from  tlie  first 
Percentage   . 


Regular  afterwards 
Percentage   . 


Never  regular    . 
Percentage 


35 
76.08 


17.37 

3 
6.52 


Total  .     . 
Percentage 


46 
21.30 


54 
71-05 

17 
22.36 

5 
6.67 


76 
35-1^ 


47 

72 

64.38 

74.24 

17 

22 

23.28 

22.67 

9 

3 

12.32 

3-09 

73 

07 

33-79 

44.90 

i:)4 
71.29 

47 
21-75 

15 
6.01 


216 


In  Table  XLV.  is  given  the  number  of  women  with  fibroids  and 
fibrous  tumors,  who,  as  to  menstruation,  were  regular  from  the  first, 


FIBROUS    GROWTHS    OF    THE    UTERUS. 


531 


regular  after  a  certain  time,  and  who  were  never  regular.  Then  the 
proportion  of  the  unmarried,  sterile,  and  fruitful  women  is  given 
together  in  the  summary,  which  includes  both  fibroids  and  fibrous 
growths.  By  this  table  we  see  confirmed  in  another  form  the  views 
which  have  been  already  expressed  as  to  the  relative  liability  of  the 
unmarried,  sterile,  and  fruitful  women  to  fibrous  growths. 

By  comparing  this  table  with  Table  III.  (page  156),  which  shows 
the  regularity  for  all  women  under  observation,  it  becomes  evident 
that  those  who  suifered  in  after  life  from  fibrous  growths  were  in 
excellent  health  at  the  time  of  puberty,  so  far  as  this  may  be  inferred 
from  the  condition  of  the  menstrual  flow.  The  proportion  of  those 
who  were  regular  from  the  first  is  essentially  the  same  as  the  general 
average.  A  larger  number  were  regular  afterwards,  and  the  propor- 
tion of  those  never  regular  is  smaller,  than  the  o-eneral  average. 

A  comparison  must  be  made  between  Table  XLVI.  and  the  standard. 
Table  V.  (page  157),  in  reference  to  the  existence  or  absence  of  pain 
with  the  first  appearance  of  the  menstrual  flow  at  puberty. 

Table  XLYI — Fibrous  Growths  loith  reference  to  Pain  during 
Menstruation. 


UQinarried. 

Sterile. 

Fruitful. 

Total. 

With,  pain  in  the  beginning  of  the  flow  . 
Percentage     

5 
31-25 

5 
31-25 

6 

37-50 

16 
7-40 

With  pain  during  the  flow    .     .     .     . 
Percentage     

13 
30-23 

23 
53-48 

7 
16.27 

43 
19.50 

Free  from  pain 

Percentage     

28 
17.77 

45 
28.66 

84 
53-50 

157 
72.68 

Total 

46 

73 

97 

216 

The  first  point  to  be  noted  in  this  comparison  is  that  those  in  whom 
growths  were  developed  afterwards  suffered  but  little  pain  in  the 
beginning  of  the  flow.  But  the  proportion  of  these  w^as  greater  than 
of  those  who  suffered  from  pain  during  the  flow,  while  about  the  same 
percentage  as  is  shown  by  the  common  standard  were  free  from  pain. 
If,  however,  we  take  each  condition  separately,  the  difference  will  be 
somewhat  more  marked.  A  larger  proportion  of  the  unmarried 
seemed  to  have  had  pain  in  the  beginning  of  the  flow  than  is  shown 
in  Table  Y.,  the  other  differences  from  the  standard  are  unimportant. 


532 


DESCRIPTIOX,   ETIOLOGY,    AND    DIAGNOSIS    OF 


On  the  other  hand  a  smaller  number  of  sterile  women  had  pain  at  the 
beginning  of  the  flow.  The  proportion  is  about  the  same  for  those 
who  suffered  pain  during  the  flow,  while  a  larger  number  were  free 
from  pain ;  thus  showing  that  Avomen  who  were  afterwards  made 
sterile  by  fibrous  growths  were  in  better  condition  at  the  time  of 
puberty  than  other  sterile  women,  in  whom  fibrous  growths  did  not 
develop.  In  general  terms  the  same  may  be  said  of  fruitful  women, 
although  a  somewhat  smaller  proportion  of  them  were  free  from  pain 
at  the  time  of  puberty  than  was  the  case  with  all  the  fruitful  women 
under  observation.  The  proportion  of  fruitful  women  who  suffered 
during  the  flow  was  also  less  than  that  for  the  sterile.  The  same 
general  law  also  holds  good  in  regard  to  those  who  suffered  from  pain 
during  the  flow,  since  the  proportion  of  sterile  women  so  suffering  is 
always  the  greatest.  It  is  true  the  number  of  fruitful  women  given 
in  Table  XLVI.  is  very  small,  and  would  be  of  little  significance  if 
the  facts  brought  out  did  not  confirm  those  given  for  the  larger 
number  of  women  under  observation. 


Table  XLYII Showing  the  connection  between  the  Regularity  of 

Menstruation  and  Degree  of  Pain. 


Regular  from 
the  first. 

Regular  after- 
wards. 

Xever  regular. 

Total 

number 

aud 

per- 
centage 

Xo.  of        Per 
cases,   j    cent. 

So.  of 
cases. 

Per 
cent. 

No.  of 
cases. 

Per 
cent. 

"With  pain  in    jf  ,t       r 
the  beginning  )  ^o.  of  cases 
of  the  flow.      (Percentage 

With  pain       f  No.  of  cases 
during  the  flow.  (  Percentage 

■n       j;             •      ( No.  of  cases 
Free  from  pain.  <  „           . 

■*           (  rercentage 

11 
7.14 

28 
18.18 

115 
72.33 

68.37 

64.97 
73.25 

2 
4.27 

10 
21.27 

35 
74.46 

12.50 

23.25 
22.29 

3 
20.00 

5 
33-33 

7 
46.66 

18.75 

11.62 
4.45 

16 
7.40 

43 
19.90 

157 
72.68 

Total  number  and  percentage    154 

71.29 

47 

21.75       15 

1 

6.94 

216 

In  Table  XL VII.  is  shown  the  relation  between  regularity  or 
irregularity  of  the  menstrual  flow  from  the  time  of  puberty,  with  the 
presence  or  absence  of  pain  at  that  time  among  women  who,  in  after 
life,  suffered  from  fibrous  growth  of  the  uterus.  Thus,  16  women  had 
pain  at  the  beginning  of  the  flow,  of  which  68.37  per  cent,  were 
regular  from  the  first,  12.50  per  cent,  after  a  certain  time,  and  18.75 


FIBROUS    GROWTHS    OF    THE    UTERUS.  533 

per  cent,  were  never  regular.  Of  these  11,  or  7.14  per  cent,  of  those 
who  were  regular,  2,  or  4.27  per  cent., of  those  who  were  regular  after- 
wards, and  3,  or  20.00  per  cent.,  of  those  never  regular,  suffered  from 
pain  at  the  beginning  of  the  flow.  It  is  here  shown  that  72.33  per 
cent,  of  all  women  who  developed  fibrous  growths  began  their  menstrual 
life  regular  and  free  from  pain.  The  absence  of  pain  was  evidently 
the  rule,  but  the  greatest  percentage  of  those  who  suffered  from  pain 
did  so  during  the  flow,  and  were  never  regular.  The  number  here 
is  also  too  small  to  be  of  anj  significance  were  it  not  in  accordance 
with  the  general  rule. 

The  tendency  during  the  development  of  a  fibrous  growth  is  hemor- 
rhagic, since  a  greater  portion  of  these  tumors  have  their  starting 
point  in  close  proximity  to  the  raucous  membrane  lining  the  uterine 
canal.  The  first  symptom  with  many  cases  is  a  loss  of  blood  from 
within  the  uterus,  and  afterwards  the  recurrence  of  hemorrhage  upon 
the  slightest  provocation  is  the  rule.  There  are  many  exceptions 
where,  although  hemorrhage  was  the  rule  in  early  life,  the  quantity 
became  less  as  the  development  progressed.  This  change  is  due  to  a 
growth  of  the  tumor  in  a  direction  where  the  circulation  would  be  but 
little  obstructed,  or  to  the  gradual  obliteration  by  the  tumor  as  it 
grows  of  the  vessels  in  its  neighborhood.  Finally,  in  a  certain  pro- 
portion of  cases,  change  of  life  takes  place,  and  the  tumor  decreases 
in  size,  and  gives  no  further  trouble,  or  it  remains  inert,  simply  an  in- 
convenience from  its  bulk.  Table  XLYIII.  shows  the  average  dura- 
tion of  the  first  menstrual  flow  of  all  women  who  suffered  in  after  life 
from  some  fibrous  growth.  It  will  be  observed  that  the  averages 
except  for  the  unmarried  are  somewhat  above  those  given  in  Table 
XI.  page  168,  which  was  taken  from  all  the  women  under  observation. 
This  is  a  slight  indication,  and  only  a  slight  one,  that  a  more  vascular 
condition  than  is  usual  exists  in  certain  women  at  the  time  of  puberty, 
and  hence  they  are  more  liable  to  the  development  of  these  growths 
in  after  life. 

It  is  usual  to  judge  of  the  condition  of  menstruation  by  the  dura- 
tion of  the  flow,  but  this  method  cannot  be  exclusively  followed  in 
studying  the  history  of  fibrous  growths,  since  it  may  mislead  us.  I 
have  known  the  length  of  the  flow  to  become  shortened  under  the  in- 
fluence of  a  fibroid,  but  more  blood  lost  than  would  be  the  case  with 
a  fibrous  tumor,  although  with  the  latter  the  duration  of  the  flow  may 
have  been  prolonged  beyond  the  average. 

We  will  at  first  present  these  changes  more  particularly  in  con- 
nection with  the  duration  than  the  quantity.     Afterwards  we  will 


534 


DESCRIPTION,   ETIOLOGY,    AND    DIAGNOSIS    OF 


consider  the  changes  in  the  quantity,  and  these  after  all  are  to  be 
regarded  as  of  the  greater  importance  practically. 

Table  XLVIII Length  of  the  Menstrual  Flow  at  Puberty,  with 

Fibroids  and  Fibrous  Tumors. 


Fibroids. 

Average  length 

of  flow  at 

puberty. 

Fibrous  tumors. 

Average  length 

of  flow  at 

puberty. 

Unmarried 

Sterile 

Fruitful 

4.66 
5.29 
5.11 

Unmarried    .... 

Sterile 

Fruitful 

4.27 
5.00 
5.27 

Average  for  all  women 

5.04 

Average  for  all  women 

5.02 

Table  XLIX Shoiving  the  Length  of  Flow  in  after-life  in  connecti 

with  Regularity  and  Pain. 


on 


With  pain  in 

the  beginning 

of  the  flow. 

With  pain 

during  the 

flow. 

Free  from 
pain. 


Number  of  cases. 

Length  of  flow. .. 

Number  of  cases. 

Length  of  flow... 
■  Number  of  cases. 
'  Length  of  flow. . . 


Regular 

from  the 

first. 


tS  fc 


Total  number    (  Number  of  cases i  154 

and  average     < 
length  of  flow.  (  Length  of  flow ■   .... 


Eegular 
afterwards 


Never 
regular. 


■f?  E= 


2  I   .... 

90  !    fl.OO 

10  I  .... 

....  I    5.00 
35 

....  5.40 


3     I   .... 

5.66 


5.85 


Total. 


»  " 


.02 


Table  XLIX.  shows  the  length  of  menstruation  in  after  life  for  all 
who  had  fibrous  groAvths,  and  with  this  is  given  the  condition  as  to  regu- 
larity, and  the  pain  suffered  by  these  women  at  the  time  of  puberty. 
The  form  of  this  table  is  the  same  as  Table  XLVII.,Avith  the  substitution 
of  the  average  length  of  menstruation  for  the  percentage  on  the  number 
of  cases,  and  the  two  should  be  studied  together.  Two  facts  are  made 
prominent  by  this  table,  viz.,  that  the  longest  duration  of  flow  in  after 
life  was  among  those  who  previously  had  suffered  pain  during  the 


FIBROUS    GROWTHS    OF    THE    UTERUS.  535 

flow,  and  that  women  who  were  never  regular  in  after  life  menstruated 
longer  at  each  period  than  the  average. 

If  we  turn  to  Tahle  L.  we  can  study  these  changes  in  the  un- 
married, sterile,  and  fruitful. 

This  table  has  been  constructed  on  the  same  general  plan  as  Table 
XII.  (page  170),  Avhich  may  be  taken  as  the  standard  in  the  study 
of  menstruation. 

The  fibroids  and  fibrous  tumors  have  each  been  divided  into  two 
classes,  the  first  made  up  of  those  with  whom  the  length  of  flow  re- 
mained as  at  puberty,  although,  with  a  certain  number,  the  quantity 
may  have  been  changed  more  or  less.  The  second  division  contains 
all  in  whom  both  time  and  quantity  were  changed  in  after  life.  Each 
division  is  subdivided  into  two  sections. 

The  first  section  of  the  first  subdivision  contains  those  with  whom 
the  flow  remained  in  after  life  the  same  as  at  puberty,  whether  normal 
too  free,  or  scanty. 

The  second  section  of  the  same  division,  contains  those  in  whom  the 
length  of  the  flow  remained  unchanged,  but  in  whom  the  quantity 
became  increased,  lessened,  or  irregular,  owing  to  the  presence  of  the 
fibrous  growth. 

We  have  then  given  the  number  of  cases,  the  average  duration, 
and  the  percentages,  on  all  these  cases  forming  this  special  division 
in  which  the  flow  remained  normal  or  too  free,  or  became  scanty,  in- 
creased, lessened,  or  irregular  ;  then  the  total  number  for  the  unmar- 
ried, sterile,  and  fruitful  women,  with  the  percentage  on  the  total 
number  for  each  condition  of  menstruation. 

The  same  information  is  given  for  all  those  in  the  second  division, 
in  the  first  section  of  which  are  given  those  in  whom  the  time  was 
lengthened,  while  the  quantity  was  increased,  lessened,  or  became 
irregular.  In  the  second  section  are  those  in  whom  the  time  became 
lessened,  and  the  quantity  lessened,  increased,  or  became  irregular. 

Then  follow  the  totals  for  all  cases  having  fibroids,  and  also  for 
those  having  fibrous  tumors  ;  and  finally  there  is  a  summary  for  all 
cases  of  fibrous  growths.  There  is  first  given  the  total  number  for 
each  condition  of  menstruation,  then  the  average  duration  of  flow,  and 
finally  the  percentage  for  each  condition  calculated  on  the  total 
number. 

There  were  eighty -four  women,  or  sixty  per  cent.,  with  fibroids,  who 
averaged  5.28  days'  duration  of  flow,  as  it  had  been  from  puberty. 
Per  contra,  fifty-six  women,  or  but  forty  per  cent,  only,  of  all  who 
suffered  from  fibroids,  did  undergo  a  change  in  the  menstrual  flow  in 


536  DESCRIPTION,   ETIOLOGY,    AND    DIAGNOSIS    OF 

Table  L Condition  of  Menstruatioii  in  After-life  as  to 


Period  bemaixed            Lexgth  of  Period  kkmaised 

UNCHA.VGED  as    to    TiJIE  AXD             ryCHA>-GED.  BCT  THE 
QUAXTITT,  BEiyO  FKOM               QUASTITT  BECAME  AFTER- 
THE  BEGIXXIXQ                                         WARDS  EITHER 

Total. 

Where  men- 
struation from 
the  beginning 

Fibroid  Tcmok3. 

Normal.     TOO  free.    Scanty.      J^,,    |     ,\-        ^"r" 

was 
unchanged 
in  duration. 

"*S     I3C       Kg      ,   X.       15      ix       ag 

iSgg-    iSsS-    |2g.^,   |§ 
"g^!f     =^'5.-!!     '^g."-     '^g 

No.  of  men- 
strual days. 

No.  of  oases 
and  por  cont. 

No.  of  moM- 
strual  days. 

No.  of  rasos 
and  por  cont. 

No.  of  iiH-n- 
strual  days. 

S5      <  = 

Si 

S 

Normal 

Too  free 

Scanty  

Increased 

Lessened 

Irregular 

6 

29  ,     .. 

..   !     4 

30 

2' 

i2 

i6' 

22.22 

58 

'3        '.'.'.'.'. 
..3         4 

'.'.      6^67     '.'. 

6    4.8323.08 
4    7.50,15.38 

2  6.00    7.69 
10    5.b0i3S.46 

1    3.00|  3.S.5 

3  4.66  11.54 

Total i     .. 

Percentage 13.33 

v.      g'.Sg 

..      4.44 

2.22 

26    5.61      .. 
..   1   ..    30.95 

r 

'Normal 8 

Too  free 

Scanty 

Increased 

Lessened 

Irregular !     .. 

36 

6* 

44  1     '.'. 
••   1     ^ 

•• 

is' 

98 

5' 

26        '.'. 

2 

io 

5  4.50'l9.51 

6  7.33  14.63 
2    4. CO;  4.S8 

IS   5.44!43.90 
5    5.20  12.20 
2    5.00    4. 88 

Total 1     .. 

Percentage 13. 11 

9-84 

..      3.28 

29.5II  .. 

8.20 

!!  3:28  ;; 

41    5.41 

48!8o 

s 

'Normal 

Too  free 

Scanty 

Increased 

Lessened 

Irregular 

4 

14 

3' 

4*   1  23 

j 

■■ 

16        '.'. 

2 

'9 

4   3.50  23.53 

3  4.66  17.65 

4  5.75  23.53 
4    4.00  23.53 
2   2.25  11.76 

Total 

Percentage 

11.76 

8.S2 

..1 

11.76 

11.76 

'.'.  j  5-88    '.'. 

17    4.47 

. .    1    .. 

20.23 

Total  No.  of  fibroids 

Average  lensrth  of  flow 

i            Percentage 

18        .. 

..    4.38 
i2.86|  .. 

13 
9.29 

4 
6.77      .. 
..      2.86 

..32       ..      10 

5.00      ..    5.. '59      .. 
..    22.861   ..      7.14 

i'.ho 

7 

..    4.71 

5-oO|    -- 

84  '    .. 
..    5.2s 

60.00 

Fibrous  Ttmobs. 

o 

E 
a 

'Normal j    3 

Too  free 1     .. 

Scanty ■     .. 

Increased 

Lessened 

Irregular 

12 

i' 

'e 

i' 

'4 

9" 

53 

i' 

'h 

4    '  26 

1 

3  4.00 
1     6.00 
1    4.00 

9   J5.88 
1    6.00 

4  [5.00 

15.79 
5.26 
6.26 

47.37 
5.26 

21.05 

Total 

Percentage 12. (x> 

4.00 

•• 

4.CXJ 

36.00 

4.00 

'.'.  !i6:<;o! :: 

19 

5.31 

38.00 

c 

'Normal 

Too  free 

Scanty  

Increased 

Lessened 

Irregular 

::  :: 

" 

7" 

45 

.. 

•• 
•  • 

'7 

6 '.42 

106! 

Total 

Percentage 

::  1  ::  !  ::  i  :: 

35 -oo 

::  !  ::  1  :: 

7   16.42 

14.00 

'Normal 

Too  free..'. 

Scanty 

Increased 

Lessened 

Irregular 

2 

9 

2' 

ie 

15' 

83 

i' 

3 

4' 

is 

2 
2 

is 

1 
4 

4.50'  8.33 
8.00   8.33 

..   1     .. 
5.53  62. .W 
3.00    4.17 
4.50  16.67 

Total 

Percentage 6.45 

•• 

6*45 

48  .'29 

3-23 

..     12.90 

24 

5.87 

48.00 

'  Total  No.  of  fibrous  tumors,     5     |   .. 

Average  length  of  flow 1     ..    4.20 

Percentage 6-58    .. 

3       ..       1 

..    7.33      .. 
3.95    ..      I. 31 

4!6o 

81 

40.79 

..   I     2 

5.83i     .. 

..   1  2.63 

..   1     8 
4.50|     .. 

..     10. S3 

4^75 

60 

a!5o    '.'. 
..  165.78 

Total  No.  of  fibrous  growths    23     j   .. 

Averatre  length  of  flow 1     ..    4.3t 

Percentage ^°-^S\   •• 

16     I   ..   1     6 

..   !6.87!     .. 

7.41.   ..      2.31 

4!80 

63 
29.17 

..   1  12 
5.71      .. 
..   1  5-56 

1 

..   1  15 
4.50      .. 
..      6.94 

4!  73 

134 

5. '36      V. 

..    62.03 

FIBROUS    GROWTHS    OF    THE    UTERUS. 
Duration  and  Quantity^  with  Fibroids  and  Fibrous  Tumors. 


537 


LENaTR  OF  Period  becamr 

Increased,  with  the 

qua.vtity  either 

Lbnoth  op  Period  became 

Les^e.ved,  with  the 
Quantity  either 

Total. 

Where  menstru- 
ation bocainii 

S 

ummary. 

In-            Loss- 
creased,       eued. 

Irregu- 
lar. 

Loss-             In-           Irregu- 

ened.       creased.  !      lar. 

1 

changed  in  time 
and  quantity. 

No.  of  cases 
and  per  cent. 

No.  of  meu- 
ptrual  days. 

No.  of  cases 
and  per  cent. 
Ni).  of  men- 
strual days. 

w  0 
0  a) 

0  a 

=  g 

0   !3 

No.  of  cases 
and  per  cent. 

No.  of  men- 
strual days. 

u 
0 

d 

Av.  length 
of  period. 

Per  cent,  for 
each  condi- 
tion. 

No.  of  cases. 

Av.  length 
of  period. 

Per  cent,  for 
each  condi- 
tion. 

9' 

io 

2 

13 

i      '3 

io" 
7 
2 

6.20 
2.71 
6.00 

52.63 
36.84 
10.53 

6 
4 
2 
20 
8 
5 

4.83  ,  13.33 
7..'50       8.89 
6.00       4.44 
6.00     44.4t 
2.7,-.  •  17.78 
5.40  I  11.11 

20.00 

::  1 :: 

4.44    .. 

15.56 

2.22 

19 

4.94 

33-92 

45 

5.33 

9' 

;;  I 

i     3' 

ii 

22 

'2 

io' 
7 
3 

V.io 

3.14 
4.66 

56.00 
3.5.00 
1.5.00 

8      4..';o 

6        7..33 

2        4.00 

28        6..39 

12        4.00 

5        4.S0 

13.11 

9.84 
3.28 
45.90 
19. C7 
8.20 

14.15 

::  1 :: 

4.92 

11.47 

1.64 

20 

5.85 

3S-7I 

CI 

5.55 

S 

70 

5 

4' 

12 

"9* 
4 
4 

s.ii 

4.25 
6.75 

52.94 
23.53 
23.53 

4 
3 

'is' 

8 
6 

3..50 
4.66 

'7.38 
4.12 
6.00 

11.76 

8.82 

3s'.24 
23.53 
17.65 

23-53 

2.04 

.. 

11.76 

8!82 

2.94 

17 

6.88 

3°-3S 

34 

5.67 

26 
18.57 

8. '60 

1  1  ..  i  9 
..  5.00  .. 
.71  ..  6.43 

eloo 

17 

..    3.11 
12.14    •• 

3 

2.14 

2!  66 

56 

5.85 

40.00 

140 

5.51 

64.81 

■• 

3S 

"e' 

6.33 

ibb! 

3 

1 
1 
15 
1 
4 

4.00 
6.00 
4.00 
6.06 
6.00 
5.00 

12.00 
4.00 
4.00 

60.00 
4.00 

16.00 

24.00 

::  1 :: 

::!  :: 

6 

6,33 

23.07 

25 

5.56 

•• 

51 

3' 

is 

"e" 
4 
3 

8.56 
4.C0 

6.00 

4'6.i5 
30.77 
23.08 

'ih' 
4 
3 

'7.38 
4.00 
6.00 

65.b'o 
20.00 
15.00 

30.00 

;:  1 ;: 

15.00 

zo.oo 

..  1  .. 

13 

6.53 

50.00 

20 

6.50 

6 

43 

i' 

'7 

'4    '.'. 

5 

1 
1 

8.  GO 
4.00 
7.00 

71.43 
14.29 
14.28 

2 
2 

'26' 
2 

6 

4..50 
8.00 

'6'..36 
3..'i0 
5.00 

6.45 
6.45 

64.52 
6.45 
16.13 

16.13 

3-23 

3.22   ,. 

7 

7.71 

26.92 

31 

5.90 

17 
22.37 

7!76 
7!90 

4 

6.07 

6 

..    4.00 
6.58    .. 

26 

6.80 

34.01 

70        -          j 
....       5.94 

3S-i8 

43 
19.91 

1 
.'46 

5.60 

13 

6.02 

22 
10.18 

sisi 

3 

1-39 

2.66 

82 

5.i.5 

37-03 

216 

6.66 

538 


DESCRIPTION,   ETIOLOGY,   AND    DIAGNOSIS    OF 


both  time  and  quantity,  and  with  these  the  average  duration  was  5.85 
days. 

The  second  part  of  Table  L.,  containing  the  history  of  fibrous  tumors, 
presents  so  much  in  common  with  that  of  fibroids,  on  all  essential 
points,  that  no  farther  comment  or  explanation  seems  necessary,  beyond 
calling  attention  to  the  general  increase  in  the  averages  for  the  length 
of  flow. 

This  table  may  be  condensed  and  summed  up  in  the  following 
Table  LI.  We  have  here  the  results  on  the  total  number  so  placed 
that  at  a  glance  the  average  length  of  flow,  and  the  proportion  for 
each  condition,  can  be  seen. 

Table  LI. — -A  Summary  of  Table  L. 


The  percentages  for  those  who  remained  normal,  too  free,  or  scanty, 
would  not  be  likely  to  vary  materially  with  larger  numbers.  But 
when  the  length-  of  flow,  changes  in  after  life,  the  quantity  of  the  flow 
should  be  considered  in  connection  with  it,  and  the  number  of  cases 
should  be  larger  to  render  the  conclusions  reliable.  By  comparing 
the  results  based  on  the  time  of  flow  as  given  in  Table  LI.,  with  those  in 
Table  LII.  based  upon  the  quantity,  we  may  arrive  at  some  accuracy  in 
regard  to  the  numbers  in  whom  the  flow  would  be  increased  or  lessened 


FIBROUS    GROWTHS    OF    THE    UTERUS.  639 

in  both  time  and  quantity.  A  greater  clifFerence  would  necessarily 
exist  between  those  irregular  in  time  and  those  irregular  in  quantity, 
since  the  two  classes  would  be  influenced  by  very  diiferent  conditions. 

We  will  now  consider  the  quantity  of  the  menstrual  flow  in  reference 
to  the  changes  which  it  underwent  from  puberty  to  the  date  of  the 
first  examination.  It  must  be  borne  in  mind  that  Table  LII,  is  based 
upon  the  changes  in  quantity,  without  reference  to  the  time  or  dura- 
tion of  the  flow.  This  constitutes  an  important  diff'erence,  since,  as 
has  been  said,  the  duration  of  flow  would  not  necessarily  indicate  the 
quantity.  Yet  it  is  essential  in  the  study  of  these  growths  to  know 
the  condition  of  the  flow  as  to  quantity,  the  duration  being  of  second- 
ary importance.  In  Table  LII.  is  given  the  average  length  of  flow 
for  fibroids  and  fibrous  tumors  separately.  It  will  be  noted  that  the 
numbers  do  not  agree  with  those  of  the  other  tables.  The  difference 
is  due  to  the  fact,  as  was  shown  in  Table  L.,  that  with  a  certain 
number  there  was  no  change  afterwards  in  consequence  of  the  pre- 
sence of  the  tumor.  Between  forty-five  and  fifty  per  cent,  of  all 
these  cases  had  an  increase  in  the  quantity  oi  the  flow,  and  in  a 
larger  proportion  with  fibroids  than  with  fibrous  tumors.  Some  seven- 
teen per  cent,  had  the  quantity  lessened  from  the  average  existing  at 
puberty,  and  the  change  Avas  the  greatest  for  fibrous  tumors.  A 
greater  proportion  were  irregular  in  the  quantity  of  the  flow,  but 
there  was  little  difference  in  this  respect  between  the  two  growths. 
Finally,  it  is  shown  that  fifteen  cases  had  already  undergone  a  change 
of  life.  Less  than  two  per  cent,  of  those  with  fibroids  had  gone 
through  the  change,  while  there  was  over  fifteen  per  cent,  for  the 
fibrous  tumors.  At  the  first  glance  this  would  seem  to  be  a  great 
difference,  and  yet  it  is  not  strange,  since  a  greater  proportion  of 
fibrous  tumors  would  be  met  with  at  a  later  period  of  life. 

This  would  be  an  important  feature  should  future  observation  of 
a  larger  number  of  cases  establish  the  fact  that  with  so  large  a  pro- 
portion a  change  of  life  takes  place  through  the  efforts  of  nature.  It 
would  necessarily  have  a  certain  weight  in  determining  a  resort  to 
extensive  surgical  measures  at  this  period  of  life.  All  Avomen  were 
excluded  who  had  had  a  show  within  a  year  previous  to  my  examina- 
tion. The  flow  ceased  at  the  following  ages:  with  1  sterile  and  1 
fruitful  woman,  each  having  a  fibroid,  at  46  years  of  age  for  each  ; 
as  to  the  fibrous  tumors,  it  ceased  with  3  unmarried  women  at  48, 
40,  and  51  years ;  with  3  sterile  women  at  39,  40,  and  48  years ; 
7  fruitful  women  underwent  the  same  change  at  the  ages  of  46,  30, 


540 


DESCRIPTION,   ETIOLOGY,    AND    DIAGNOSIS    OF 


47,  54,  60,  46,  and  58 — making  45.53  the  average  age  for  cessation 
of  menstruation  in  those  who  had  fibrous  tumors. 


Table  LII Average  Length  of  Flow,  given  for  Fibroids  and  Fibrous 

Tumors  separately. 


No.  of 
cases. 

Character  of  growth. 

Average 

length  of 

flow  at 

puberty. 

After  change  in  the 
flow. 

Length  of 

flow 

afterwards. 

Percentage 

for  each 

condition. 

52 

35 

Fibroid    .... 
Fibrous  tumor . 

5.00 

4.71 

Increased  ....-< 

7.26 
6.88 

50.98 

41.17 

19 
14 

Fibroid    .... 
Fibrous  tumor  . 

5.10 
5.38 

i 
Lessened    .   .   .  .  < 

3.21 

2.81 

18.62 
16.47 

29 
23 

Fibroid    .... 
Fibrous  tumor . 

Irregular  .   .  .   . < 

5.73 
5.54 

28.43 
27.05 

2 
13 

Fibroid    .... 
Fibrous  tumor . 

Ceased  from          J 
change  of  life  .  i 



1.96 
15.29 

We  find  that  these  fibrous  growths  seem  to  have  had  but  little 
influence  in  lessening  the  average  number  of  children  to  each  woman. 
On  reaching  a  certain  stage  of  development  the  tumor  unquestionably 
caused  a  number  of  miscarriages,  and  finally  a  condition  of  permanent 
sterility.  But  before  the  fibrous  growths  existed,  or  while  yet  in 
their  incipiency,  these  women  were  unusually  prolific.  This  is  true 
since  the  average  number  of  impregnations  for  them  is  quite  as  great 
as  that  taken  on  the  general  average.  Thus  1249  fruitful  women 
under  observation  had  given  birth  to  3550  children  at  full  term,  and, 
in  addition,  had  miscarried  1009  times,  making  4559  impregnations, 
or  an  average  of  3.57  pregnancies  for  each  woman. 

Eighty-three  fruitful  women  with  fibroids  averaged  2.34  children 
at  full  term,  or,,  including  miscarriages,  exactly  three  impregnations 
for  each  woman,  and  in  the  proportion  of  78.31  per  cent,  of  children 
to  21.69  per  cent,  of  miscarriages.  The  last  pregnancy  occurred  at 
the  age  of  27.63  years,  and  the  condition  of  sterility  had  averaged 
8.01  years  previous  to  the  first  examination. 

Thirty-four  fruitful,  suffering  in  after  life  from  fibrous  tumors,  gave 


FIBROUS    GROWTHS    OF    THE    UTERUS.  541 

birth,  at  full  term,  to  111  children,  an  average  of  3.2G  children 
each,  and  including  82  miscarriages  the  percentage  Avould  be  4.20 
impregnations  for  each  woman.  This  would  be  in  the  proportion  of 
77. G2  per  cent,  of  children  and  22.87  per  cent,  of  miscarriages. 

With  fibrous  tumors,  the  average  for  the  fruitful  at  the  time  of  first 
consultation  was  40.28  years,  as  already  given.  The  average  length 
of  time  since  the  birth  of  the  last  child  was  11.40  years,  which  would 
make  the  average  acre  28.88  vears  for  these  cases,  and  the  last  mis- 
carriage  to  have  occurred  at  the  average  age  of  81.06  years. 

By  referring  to  Table  XLII.,  it  will  be  found  that  the  average  age 
of  miscarriage  was  18.02,  for  the  women  with  fibroids.  Table  XLIII. 
gives  24.68  as  the  average  age  for  fibrous  tumors,  and  Table  XLIV. 
21.20  years  as  that  for  all  cases  of  fibrous  growths.  This  would  give 
in  round  numbers  3  children,  or  4.20  impregnations  in  6.38  years  for 
each  woman  having  a  fibrous  tumor  afterwards. 

Should  these  statistics  be  confirmed  by  future  observation  on  a  larger 
number  of  women,  the  inference  might  be  drawn  that  an  unusual 
number  of  impregnations  within  a  limited  time  is  as  conducive  to 
fibrous  growths  as  is  the  condition  of  idleness  or  absolute  rest  of  the 
uterus. 

Diagnosis  of  Fibrous  Cfroivths. — In  the  early  stages  of  a  develop- 
ing fibrous  growth,  a  patient  will  seek  relief  from  symptoms  due  to 
uterine  displacement,  such  as  irritation  of  the  bladder,  pressure  on 
the  rectum,  or  a  general  feeling  of  fulness  about  the  pelvis,  with  an 
irregular  show,  or  the  menstrual  flow  too  free.  The  patient  is  to  be 
placed  on  the  back  for  an  examination,  and  this  should  be  first  made 
with  the  index  finger  of  the  left  hand  in  the  vagina,  while  using  the 
right  one  for  manipulating  over  the  pubes.  The  uterus  will  generally 
be  detected  by  the  finger  to  be  lower  in  the  pelvis  than  natural,  and 
the  first  impression  will  be  that  the  organ  is  very  much  displaced, 
either  backward,  forward,  or  to  one  side  or  the  other.  But  if  the 
examination  be  continued  with  the  aid  of  the  other  hand  over  the 
abdominal  wall,  the  information  will  be  soon  gained  that  although  the 
uterus  is  evidently  enlarged,  it  is  more  flattened  in  shape  than  natural. 
That  is,  the  uterus  will  seem  much  wider  or  thicker  transversely  than 
it  should  be,  in  proportion  to  its  apparent  length,  as  felt  between  the 
two  hands.  Or  the  uterus  may  seem  too  long  for  its  width.  In  addi- 
tion, the  surface  of  the  enlarged  uterus  may  be  found  irregular,  or  a 
grooved  surface  on  opposite  sides  may  be  detected,  which  would  give 
the  impression  as  if  a  large  rounded  body  projected  from  the  uterine 
wall.     By  this  time  the  examiner  will  have  made  up  his  mind  as  to 


54:2  DESCRIPTTOX,   ETIOLOGY,    A^'D    DIAGNOSIS    OF 

the  existence  of  a  fibrous  tumor,  or  be  m  doubt  between  a  flexure  of 
the  uterine  body  and  a  fibroid  on  the  uterine  Avail.  This  point  he 
may  not  be  able  to  settle  without  resorting  to  the  use  of  the  uterine 
probe  to  determine  the  direction  of  the  canal.  It  is  customary  to 
state  that  the  presence  of  a  fibrous  growth  may  be  mistaken  for  preg- 
nancy, cellulitis,  hsematocele,  extra-uterine  pregnancy,  or  ovarian 
tumor.  One  thing  should  never  be  mistaken  for  another,  and  to  avoid 
this  it  requires  but  a  few  moments  longer  in  the  examination,  that 
we  may  not  form  any  conclusion  until  the  investigation  has  been 
thoroughly  made.  Even  should  the  history  of  the  case  give  no  sus- 
picion of  pregnancy,  an  enlarged  uterus,  if  movable,  should  not  be 
mistaken  for  either  of  the  other  conditions.  Frequently  the  growth 
of  a  fibroid  excites  inflammation  in  its  neighborhood,  so  that  the  case 
becomes  complicated  by  cellulitis,  and  under  these  circumstances  the 
presence  of  a  fibroid  may  remain  for  a  time  in  doubt.  But  I  hold  it 
would  be  due  only  to  the  grossest  carelessness  should  an  hgematocele 
or  the  slightest  cellulitis  exist  and  not  be  detected.  The  reader  can- 
not be  too  much  impressed  with  the  importance  of  assuming  the  ex- 
istence of  cellulitis  in  every  case,  until  the  contrary  be  proved,  and 
then  to  be  on  the  constant  lookout  for  it  afterwards.  And  I  may  add 
this  rule  is  equally  an  excellent  one  to  adopt  in  general  practice,  with- 
out reference  to  any  special  lesion.  An  extra-uterine  pregnancy  is 
generally  accompanied  by  a  slight  show  from  time  to  time,  and  the 
uterus  is  always  enlarged,  but  a  careful  examination  would  readily  dis- 
tino-uish  the  relation  of  the  uterus  to  an  extensive  tumor  in  one  of  the 
Fallopian  tubes,  or  to  an  abdominal  foetation  in  the  posterior  cul-de- 
sac.  No  investigation  should  be  considered  complete  until  after  a 
rectal  examination  has  been  thoroughly  made.  The  existence  of 
cellulitis  may  be  thus  detected,  and  its  extent  be  more  fully  appre- 
ciated than  is  possible  by  the  vagina  alone.  This  mode  of  examina- 
tion is  the  only  one  on  which  an  opinion  of  any  value  can  be  based  in 
regard  to  an  extra-uterine  pregnancy,  and  the  sac  containing  fluid 
can  be  thus  readily  distinguished  from  the  unyielding  uterine  walls. 
A  small  cyst  of  the  ovary  will  sometimes  occupy  Douglas's  cul-de-sac, 
and,  without  the  rectal  examination,  might  be  mistaken  for  a  fibroid. 
If  it  be  deemed  prudent,  in  the  absence  of  cellulitis,  to  introduce 
anything  within  the  uterine  canal,  Siras's  elevator  may  be  used  for  the 
purpose  of  forming  a  diagnosis.  This  instrument  has  been  already 
described  on  page  28,  and  for  this  purpose  it  is  far  preferable  to  the 
sound.  It  can  be  passed  into  the  canal,  and  the  intra- uterine  stem 
then  secured  at  any  angle  by  means  of  the  slide.    With  the  aid  of  this 


FIBllOUS    GROWTHS    OF    THE    UTERUS.  543 

instrument  the  uterus  is  brought  entirely  under  the  control  of  the 
operator.  By  placing  one  hand  over  the  abdomen,  or  with  the  index 
finger  in  the  rectum,  the  uterus  can  be  lifted  in  the  pelvis,  or  moved 
in  any  direction  by  the  instrument,  so  as  to  aflFord  an  accurate  idea 
of  its  connection  with  an  ovarian  tumor  or  suspected  pedunculated 
fibrous  tumor. 

In  case  of  doubt  as  to  the  position  of  the  fibroid,  and  whether  it  is 
advisable  to  introduce  the  probe,  it  had  better  be  done  with  the  patient 
on  the  side,  and  by  aid  of  the  speculum.  We  are  to  use  the  instru- 
ment simply  as  a  probe,  passing  it  with  the  same  care.  When  this 
is  done  we  can  arrive  at  an  accurate  knowledge  as  to  the  direction 
and  depth  of  the  canal.  I  therefore  repeat  in  substance  what  has 
already  been  stated  in  regai'd  to  the  use  of  the  sound,  that  it  fre- 
quently excites  inflammation  ;  it  is  attended  with  more  or  less  pain ; 
and  it  misleads  by  making  the  uterus  conform  to  its  own  curve. 
After  its  introduction  it  requires  but  little  art  in  manipulating,  by 
pressing  the  probe  against  the  sides  of  the  canal,  or  by  use  of  the 
finger,  to  give  it  the  proper  curve  or  direction,  and  this  can  be  done 
so  as  not  to  cause  pain  or  bleeding.  If  the  probe  can  be  introduced 
without  difficulty,  it  will  be  quite  evident  that  the  fibroid  does  not 
project  into  the  canal,  but  lies  deep  within  the  uterine  tissue.  The 
introduction  of  the  finger  within  the  uterine  canal  necessitates  that  it 
shall  be  dilated.  This  is  done  by  means  of  sponge  tents,  and  the 
rules  already  given  for  their  use  must  be  carefully  observed.  By 
means  of  the  finger  within  the  uterine  canal,  as  the  organ  is  pressed 
down  into  the  pelvis  and  steadied  by  the  hand  over  the  abdomen,  a 
diagnosis  can  be  accurately  formed  and  the  proper  treatment  decided 
upon.  After  ascertaining  the  size  and  general  situation  of  the  tumor, 
it  Avill  then  be  necessary  to  determine  accurately  what  proportion,  if 
any,  of  the  tumor  projects  into  the  canal,  or  if  the  mass  has  already 
become  pedunculated.  But  little  difficulty  Avill  be  experienced  in 
obtaining  all  the  necessary  information,  unless  the  growth  is  situated 
directly  at  the  fundus.  When  in  this  position  the  most  dexterous 
may  not  be  able  to  reach  the  base.  The  plan  I  folloAV  is  to  pass  into 
the  canal  a  strong  tenaculum  along  my  finger,  and  then  bury  it  deep 
into  the  tissue  just  within  the  os.  Then  as  the  fundus  is  pressed 
down  by  the  hand  of  an  assistant,  and  drawn  to  the  vaginal  outlet  by 
the  tenaculum,  the  finger  can  be  readily  advanced  by  giving  it  a  slight 
rota  tins;  motion.  The  neck  of  the  uterus  can  be  drawn  down  to  the 
vaginal  outlet  with  safety,  provided  it  be  done  without  jerking  and 
only  by  steady  traction.     This  position  Avill  enable  the  operator  to 


54-4  DESCRIPTION,   ETIOLOGY,   AND    DIAGNOSIS    OP 

reach  the  fundus  from  the  vaginal  outlet,  unless  the  tumor  is  a  very 
laro-e  one.  It  will  then  be  necessary  to  administer  an  anaesthetic  and 
introduce  the  whole  hand  into  the  vagina,  by  which  means  the  fundus 
can  be  reached.  Before  attempting  to  pass  the  hand  it  should  be 
thoroughly  softened  in  hot  water,  and  well  greased.  I  generally  at 
first  press  back  the  perineum  for  a  few  moments  as  far  as  possible, 
with  two  or  three  fingers,  by  gentle  but  steady  pressure.  If  the  soft 
parts  be  then  thoroughly  greased,  the  hand  can  be  introduced  by 
placing  the  tips  of  the  fingers  together  in  the  shape  of  a  cone.  But 
it  should  not  be  forced  directly  in,  but  advanced  by  rotating  the  hand 
slowly  as  the  perineum  is  pressed  backward.  Unless  favored  by 
some  peculiar  condition,  not  the  slightest  laceration  or  danger  should 
follow  this  mode  of  examination  if  it  be  conducted  with  due  care. 

The  uterus  should  always  be  restored  to  its  proper  position  after 
having  been  thus  dragged  down,  since,  if  this  is  not  observed,  inflam- 
mation can  be  as  readily  excited  as  if  force  had  been  used  in  the  dis- 
placement. A  large  vaginal  injection  of  hot  water  is  of  the  greatest 
value  after  such  an  examination,  as  it  will  check  bleeding,  reduce  the 
risk  of  bad  consequences,  and,  by  exciting  contraction,  will  cause  the 
vagina  to  return  rapidly  to  its  normal  size. 

After  the  uterus  has  become  enlarged  to  the  size  of  the  later  months 
of  pregnancy,  a  mistake  in  diagnosis  may  occur  from  a  careless  exami- 
nation, as  between  pregnancy,  fibrous  growth,  and  ovarian  tumor.  To 
fail  in  recognizing  the  pregnancy  would  be  unpardonable,  with  the 
history  of  the  case,  and  the  certainty  of  detecting  the  sounds  of  the 
foetal  heart.  The  fact  is  that  the  same  rule  should  be  observed,  as  a 
matter  of  precaution,  in  regard  to  pregnancy,  as  I  have  advised  for 
cellulitis.  Pregnancy  so  often  occurs  when  least  expected,  and  often 
under  such  singular  circumstances,  that  I  recognize  the  importance  in 
every  case  of  being  always  on  my  guard.  Unless  the  tumor  be  yet 
small,  the  blue  appearance  of  the  vagina  cannot  be  depended  upon  as 
evidence  of  pregnancy,  since  this  is  simply  an  indication  of  a  some- 
what obstructed  venous  circulation,  and  the  same  can  be  brought 
about  by  pressure  from  a  fibrous  tumor  if  it  be  sufficiently  large. 
Whenever  the  uterus  has  become  much  enlarged  from  a  fibrous  tumor, 
its  surface  is  rarely  smooth,  and  with  a  little  care  a  number  of  promi- 
nent projections  and  inequalities  can  be  detected  as  the  result  of  as 
many  different  growths. 

The  rules  for  the  differential  diagnosis  between  a  fibro-cystic  tumor 
of  the  uterus  and  an  ovarian  tumor,  and  for  the  treatment,  will  be 
pointed  out  when  we  come  to  consider  ovarian  tumors. 


FIBROUS    GROWTHS    OF    THE    UTERUS.  545 


CHAPTER    XXVIII. 

LOCAL  AND  GENERAL  TREATMENT  OF  FIBROUS  GROWTHS 
OF  THE  UTERUS. 

Action  of  ergot,  opium,  alum,  gallic  acid,  cinnamon — Incision  of  tumor — Enucle- 
ation— Partial  removal — Disintegration — Tax^ping  a  fibro-cyst. 

All  our  efforts  in  the  treatment  of  fibrous  growths  are  to  be  directed 
with  a  view  to  their  removal,  when  it  can  be  done  with  a  reasonable 
degree  of  safety,  or  to  arresting  their  development  if  possible,  while 
■we  are  to  preserve  the  patient's  strength  by  checking  the  constant 
tendency  to  a  loss  of  blood. 

That  this  subject  may  be  made  the  more  intelligible  to  the  reader, 
we  will  treat  of  the  method  for  removal  after  first  considerins;  the 
means  to  be  employed  in  the  general  treatment.  Different  agents 
have  been  put  forward,  from  time  to  time  as  efficacious  in  causing 
absorption  of  these  growths,  but  as  yet  none  have  fairly  stood  the 
test.  We  are  to-day  ignorant  of  any  means  by  which  a  hard  fibroid 
can  be  removed  from  the  uterine  tissue,  except  by  extirpation,  yet 
they  do  sometimes  disappear  through  the  unaided  efforts  of  nature, 
but  we  are  in  the  dark  as  to  the  exact  process. 

We  have  already  described  the  marked  difference  existing  in  the 
density  and  character  of  the  tissue  forming  these  tumors.  The  round 
and  dense  fibroid  possesses  so  little  vitality,  in  consequence  of  its  limited 
supply  of  blood,  that  it  is  evident,  little  or  nothing  can  be  accomplished 
for  its  absorption.  But  we  have  seen  that  there  are  other  forms  of 
these  growths,  possessing  more  of  the  muscular  structure  of  the  uterus, 
which  were  developed  faster,  and  are  more  vascular.  Klebs  has  de- 
scribed, as  we  have  stated,  the  mode  of  development  by  which  these 
tissues  are  left  filled  with  cavities  in  which  large  quantities  of  fluid 
sometimes  accumulate.  Experience  has  taught  me  that  in  these  cases 
a  great  reduction  in  bulk  may  sometimes  be  effected  by  treatment 
directed  towards  promoting  absorption  of  these  fluids,  and  towards 
diminishing  the  amount  of  blood  within  them ;  but  no  permanent  in- 
fluence is  exerted  on  the  tissues  themselves.  General  treatment, 
moreover,  is  of  service,  since  no  fact  is  better  established  from  obser- 
vation than  that  by  improving  the  health  the  development  of  tumors 
35 


546  LOCAL    AND    GENERAL    TREATMENT    OF 

will  be  delayed,  while  it  is  always  the  more  rapid  as  the  general  con- 
dition becomes  impaired. 

Drs.  Churchill  and  Savage  recommended  for  this  the  use  of  iodine  ; 
Simpson  and  Wells,  the  bichloride  of  mercury ;  Simpson,  the  bromide 
of  potassium;  Rigby  and  McClintock,  the  chloride  of  calcium.  The 
mineral  Avaters  containing  the  bromides  have  been  thought  to  be  effi- 
cacious. Ergot  has  been  extensively  employed  by  different  methods, 
but  until  recently  in  an  empirical  manner.  For  electrolysis  much 
was  claimed  by  passing  the  current  through  these  tumors  by  means 
of  long  needles  introduced  deep  into  their  structure.  Electrolysis 
may  have  been  employed  in  some  cases  with  benefit,  but,  as  a  rule, 
the  contrary  has  been  the  result,  while  its  use  is  certainly  often 
attended  with  danger.  This  danger  consists  in  the  risk  of  exciting 
peritonitis  or  inflammation  within  the  tissues  of  the  tumor,  and  I 
have  known  of  several  deaths  to  result  from  the  practice.  I  have 
seen  beneficial  results  after  the  long  use  of  small  doses  of  the  bi- 
chloride of  mercury,  in  combination  with  an  infusion  of  some  one  or 
more  of  the  bitter  vegetable  tonics,  but  the  effect  has  simply  been 
due  to  the  improvement  in  the  general  condition.  Sir  James  Y. 
Simpson  held  that  to  gain  the  full  eff'ects  of  the  bromide  of  potassium 
it  was  necessary  to  employ  the  remedy  continuously  for  months,  and 
even  a  year  or  more.  I  have  had  no  experience  with  it  thus  em- 
ployed, but  from  its  use  for  a  limited  period  I  have  never  seen  any 
eifect  beyond  a  beneficial  one  on  the  nervous  system.  If  its  long-con- 
tinued use  should  have  the  effect  of  bringing  about  absorption  of  any 
portion  of  the  tumor,  the  benefit  would  likely  be  but  temporary.  This 
I  naturally  infer,  since  there  is  always  danger  of  producing  anaemia 
by  the  long  use  of  the  bromides.  The  chloride  of  calcium  I  have 
never  employed,  but  beneficial  results  have  doubtless  followed  its 
systematic  use.  The  effect  has  been  to  bring  about  a  calcareous 
degeneration  in  the  tissues  of  the  tumor,  but  unfortunately  it  has  been 
found  that  the  coats  of  the  arteries  are  likely  to  undergo  degeneration 
also. 

One  cardinal  rule  is  to  be  observed  in  the  treatment  of  these  fibrous 
growths  :  we  must  do  nothing  by  which  the  vitality  of  the  tumor  may 
be  destroyed  while  it  is  in  situ,  since  we  then  burden  the  case  with 
the  extra  risk  from  blood  poisoning.  We  are  to  employ  any  means 
by  which  the  circulation  can  be  reduced  and  continued  at  the  lowest 
point,  short  of  its  entire  arrest.  For  this  purpose  the  action  of  hot- 
water  injections,  of  iodine,  and  the  judicious  use  of  ergot  will  be 
found  most  beneficial. 


FIBROUS    GROWTHS    OF    THE    UTERUS.  547 

From  the  injudicious  use  of  ergot  in  large  quantities  much  harm 
has  resulted  without  the  relation  of  cause  and  effect  being  recognized. 
But,  as  a  rule,  great  benefit  follows  its  use  when  administered  in  small 
and  continued  doses,  with  the  view  of  acting  on  the  coats  of  the 
vessels  and  of  exciting  only  moderate  contraction  of  the  uterine  tissue. 
Ergot  should  never  be  given  in  large  doses  until  after  the  utei-ine 
canal  has  been  dilated,  and  until  it  be  found  that  the  tumor  projects 
sufficiently  to  warrant  the  belief  that  it  may  become  pedunculated  by 
uterine  contraction.  I  have  committed  this  error  myself,  and  have 
likewise  frequently  observed  it  in  the  practice  of  others.  Should  a 
tumor  be  found  buried  in  the  uterine  walls,  or  so  situated  that  it 
cannot  become  pedunculated,  large  doses  of  ergot  can  certainly  accom- 
plish no  good.  But,  on  the  contrary,  if  the  uterus  be  thus  excited  to 
violent  contraction  without  a  purpose,  as  it  Avere,  an  increased  quan- 
tity of  blood  will  naturally  flow  to  the  parts,  often  with  the  direct 
result  of  causing  cellulitis  and  even  peritonitis.  By  thus  setting  up  a 
new  source  of  irritation  we  will  establish  the  most  favorable  condition 
for  increasing  the  growth  of  the  tumor. 

Ergot  has  been  administered  by  the  stomach,  by  the  rectum,  by  the 
vagina,  and  even  injected  directly  into  the  tissues  of  the  tumor,  but 
its  introduction  by  subcutaneous  injection  is  likely  to  be  the  method 
which  will  come  into  general  use. 

Dr.  Hilderbrandt,  of  Konigsberg,  has  published^  a  report  of  nine 
cases  treated  in  this  manner.  He  used  a  solution  of  the  watery  ex- 
tract of  ergot,  in  the  proportion  of  three  parts  to  a  little  over  seven 
parts  of  distilled  water,  with  the  same  quantity  of  glycerine.  He 
found  the  alcoholic  solution  of  Langenbeck  to  cause  pain,  and  claims 
for  his  solution  that  it  is  free  from  this  objection,  and  is  less  likely  to 
cause  local  irritation.  He  recommended  "Pravaz's  syringe,"  but  the 
ordinary  hyperdermic  one  will  answer  perfectly  for  the  purpose.  The 
point  of  introduction  he  selected,  was  in  the  neighborhood  of  the  um- 
bilicus, as  he  found  this  region  less  sensitive  to  puncture  than  the 
lower  portion  of  the  abdomen.  In  the  first  case,  the  tumor  was  as 
large  as  at  the  seventh  month  of  gestation.  He  employed  the  injec- 
tion every  day  for  fifteen  weeks,  except  at  the  menstrual  period,  at 
the  end  of  w^iich  time  the  tumor  had  disappeared. 

A  great  improvement  is  reported  to  have  taken  place  in  the  other 
eight  cases,  but  the  results  were  not  so  well  marked.     At  my  request 

'  Treatment  of  Uterine  Fibroids,  by  Subcutaneous  use  of  Ergot.     Am.  Journ.  of 
Obstetrics,  Nov.  1872,  from  the  Berlin  Klin.  Woch.,  June  17,  1872. 


548  LOCAL    AND    GENERAL    TREATMENT    OF 

Dr.  Bache  Emmet  employed  this  mode  of  treatment  in  a  number  of 
cases,  some  of  whom  have  remained  for  several  years  under  observation, 
with  the  view  of  testing  its  value.  In  no  single  instance  has  the 
tumor  disappeared,  but  with  a  number  there  was  a  marked  decrease 
in  size,  while  with  others  no  change  was  noticed.  It  is  evident  that 
the  decrease  in  size  is  only  permanent  as  an  exception  to  the  rule, 
and  the  use  of  the  ergot  has  to  be  indefinitely  continued.  Yet  when 
so  much  can  sometimes  be  gained  in  checking  the  loss  of  blood,  and  in 
adding  to  the  comfort  of  the  patient,  the  means  should  be  employed  as 
lono-  as  benefit  continues.  But  from  some  unexplained  cause,  in  some 
cases,  ergot  seems  to  act  as  an  irritant,  and  increases  the  tendency  to 
hemorrhage  after  its  long- continued  use. 

We  may  look  for  something  in  the  future  in  the  treatment  of  fibroids 
from  a  carefully  regulated  diet  consisting  chiefly  of  animal  food.  Dr. 
Ephraim  Cutter,  of  Cambridge,  Mass.,  has  reported'  seven  cases  with 
all  of  whom  a  marked  change  was  effected.  He  states :  "  For  the  idea 
the  writer  is  indebted  to  Dr.  J.  M.  Salisbury,  of  Cleveland,  Ohio. 
He  regards  these  growths  as  pre-eminently  due  to  the  excess  of  carbo- 
hydrates, starches,  sugars,  and  fermentable  food  in  the  diet ;  that  they 
are  largely  disorders  of  nutrition,  and  that  by  feeding  patients  on  a 
diet  composed  of  animal  food,  the  condition  which  was  most  potent  iu 
bringing  on  the  diseased  results  is  removed,  and  the  system  enabled 
to  right  itself  by  its  own  recuperative  powers."  Dr.  Cutter  gives  a 
carefully  selected  diet  list  which  might  be  found  also  serviceable  for 
other  forms  of  disease.  I  can  state  nothing  from  personal  observation 
on  this  subject.  At  my  request  Dr.  Bache  Emmet  has  also  made  a 
test  of  this  mode  of  treatment ;  the  number  so  treated,  however,  has 
been  limited,  and  the  time  too  short,  but  he  reports  that  in  several 
instances  there  has  been  a  marked  decrease  in  size  of  the  tumors. 

It  is  all  essential  that  the  general  treatment  should  be  directed  so 
as  to  include  every  means  adapted  to  improving  the  health.  The 
patient  should  remain  in  the  recumbent  position  at  the  time  of  men- 
struation, or  when  accidentally  flowing.  But  at  other  times  she  should 
be  as  much  as  possible  in  the  open  air,  as  the  chief  means  at  her 
command  for  maintaining  her  strength.  When  this  cannot  be  done  a 
resort  must  be  made  to  the  use  of  the  sun-baths  to  keep  up  the  proper 
proportion  of  red  globules  in  the  blood. 

The  preparations  of  iron  frequently  seem  to  increase  the  tendency 

I  "Food  as  a  Medicine  in  Cases  of  Uterine  Filn-oids."  Am.  Journ.  of  Obstetrics, 
Oct.  1877. 


FIBROUS    GROWTHS    OF    THE    UTERUS.  549 

to  a  loss  of  blood,  but  if  the  action  of  sunlight  on  the  skin  be  kept 
up,  the  remedy  will  be  less  likely  to  cause   disturbance.      In  the 
treatment  of  two  cases  recently,  I  have  been  particularly  pleased 
with  the  marked  improvement  following  the  use  of  Wyeth's  prepa- 
ration of  dialyzed  iron.     In  both  instances  other  forms  of  iron  had 
caused  headache  and  constipation,  and  an  unexpected  loss  of  blood. 
The  condition  of  the  bowels  must  be  a  constant  care,  since  if  they  are 
allowed  to  become  habitually  constipated  the  difficulty  will  necessarily 
increase  with  the  enlargement  of  the  tumor,  and  loss  of  tone  in  the 
colon  from  over  distension.     It  is,  moreover,  all  important  to  avoid 
any  additional  pressure,  since  the  most  serious  consequence  will  in  the 
end  result  from  this  long-continued  obstruction  to  the  circulation  in 
its  return  from  the  pelvis  to  the  portal  system.     This  condition  will 
constantly  subject  the  patient  to  unnecessary  loss  of  blood,  and  thus 
aid  materially  in  adding  to  the  growth  of  the  tumor.     As  the  tumor 
increases  in  size  it  will  become  more  difficult  to  keep  the  bowels 
cleared  out,  or  to  relieve  the  constant  tendency  to  an  accumulation  of 
flatus  Avhich  adds  so  much  to  the  discomfort  of  the  patient.     A  re- 
stricted meat  diet  would  be  of  benefit  under  these  circumstances  if  it 
had  no  other  effect.     The  patient  would  necessarily  be  made  more 
comfortable  bv  food  in  the  most  concentrated  form.     The  advantasre 
would  be  that  the  excrementitious  portion  would  be  small,  and  but 
little  material  could  be  furnished  to  excite  the  generation  of  flatus. 
If  the  constipation  cannot  be  relieved  by  regulating  the  diet,  it  will 
be  necessary  to  combine  the  inspissated  ox-gall  with  any  other  remedy 
indicated.     Much  relief  will  also  be  afforded  by  the  occasional  use  of 
calomel  and  soda,  if  the  strength  of  the  patient  will  admit  of  a  prompt 
action  on  the  bowels.     At  the  same  time  we  must  not  be  deceived  bv 
the  apparently  exhausted  state  of  the  patient,  who  may  be  suffering 
from  blood  poisoning  due  to  the  condition  of  the  bowels.    Under  these 
circumstances  we  cannot  find  a  better  tonic  than  a  brisk  mercurial 
purgative,   or  a  remedy  which  will  so  promptly  check  an  existing 
hemorrhage.     The  tendency  to  an  accumulation  in  the  bowels  can  be 
obviated  by  the  use  of  injections  of  warm  or  hot  water  and  ox-gall 
into  the  rectum,  while  the  patient  rests  on  the  knees,  chest,  and 
elbows.    This  injection  will  often  not  all  come  away  by  a  single  action 
of  the  bowels,  but  a  large  portion  may  be  retained  for  a  few  hours  in 
the  colon,  by  which  means  the  scybalae  will  become  dissolved  through 
the  action  of  the  ox-gall. 

In  the  early  stages  it  is  all  important  to  correct  a  retroversion  or  a 
tendency  to  prolapse  of  the  uterus  from  increased  weight.     As  the 


550  LOCAL    AND    GENERAL    TREATMENT    OF 

disease  advances  it  is  necessary  also  to  get  the  tumor  out  of  the  pelvis 
into  the  abdominal  cavity,  and  the  attempt  should  not  be  delayed 
until  after  the  mass  begins  to  cause  disturbance  from  pressure. 

Retroversion  -will  be  caused  by  a  fibroid  on  the  posterior  wall  of 
the  uterus,  or,  as  was  first  pointed  out  by  Dr.  Sims,  by  a  growth 
situated  in  front,  but  low  enough  down  to  furnish  a  leverage,  by  which 
the  fundus  is  tilted  over  through  the  action  of  the  bladder.  These 
displacements  must  be  corrected  by  the  proper  application  of  a  pes- 
sary, since  a  fibroid  will  increase  rapidly  in  size  if  allowed  to  remain 
in  a  position  where  the  circulation  is  constantly  obstructed.  When 
the  growth  has  increased  in  size  to  a  fibrous  tumor  the  fundus  some- 
times becomes  crowded  into  the  hollow  of  the  sacrum,  forcing  the  os 
above  the  pubis.  At  length  an  increase  of  size  will  render  it  impera- 
tive that  the  position  be  corrected,  and  it  will  frequently  prove  most 
difficult  to  do  so  even  with  the  aid  of  an  anaesthetic.  Yet,  usually, 
with  a  little  manipulation,  and  by  the  aid  of  gravity  brought  into  play 
by  placing  the  patient  on  the  knees  and  elbows,  it  can  be  accom- 
plished. A  tenaculum  must  be  hooked  into  the  cervix,  lying  behind 
the  symphysis,  for  the  purpose  of  drawing  it  upward  and  towards  the 
vaginal  outlet,  at  the  same  time  that  moderate  pressure  is  made  in 
the  opposite  direction  by  a  sponge  probang,  through  the  cul-de-sac 
against  the  posterior  wall  of  the  uterus.  We  must,  however,  bear  in 
mind  the  fact  that  sometimes  these  tissues  undergo  fatty  degeneration 
from  long  pressure,  and  may  be  then  easily  ruptured. 

Case  XXIX. — About  nine  years  ago  an  unmarried  woman  with 
a  large  fibrous  tumor  was  sent  to  the  Woman's  Hospital  by  Prof. 
Cabell,  of  the  University  of  Virginia.  In  this  patient  the  uterus  was 
very  much  retroverted  by  the  large  tumor  in  front,  and  the  organ 
itself  had  already  reached  a  size  when  the  action  of  the  rectum  and 
bladder  had  become  seriously  interfered  with.  I  placed  her  on  the 
knees  and  chest,  and  used  Sims's  speculum  to  open  the  canal.  My 
chief  purpose  was  to  lift  the  cervix  by  means  of  the  tenaculum,  and 
while  I  steadied  the  uterus  with  a  large  sponge  probang  placed  in  the 
cul-de-sac,  I  was  not  conscious  of  making  undue  pressure.  Suddenly 
the  cul-de-sac  split  entirely  across  the  vagina  with  as  little  resistance  as 
would  be  offered  were  it  formed  of  so  much  Avet  paper.  With  the  air 
suddenly  rushing  in  through  the  opening  thus  made,  the  probang,  some 
nine  inches  in  length,  was  drawn  out  of  my  fingers,  and,  being  carried 
by  the  current,  almost  disappeared  in  the  abdominal  cavity,  whence 
only  after  much  difficulty  I  succeeded  in  withdrawing  it  by  means  of 
a  pair  of  forceps.  The  uterus  was  replaced  by  the  force  of  the  atmo- 
sphere, and  the  patient  was  unconscious  of  any  other  sensation  than 
one  of  relief.     I  placed  a  sponge  in  the  wound  to  collect  the  blood 


FIBROUS    GROWTH    OF    THE    UTERUS.  551 

and  to  prevent  the  escape  of  intestines,  while  ether  was  administered 
to  the  patient,  who  took  it  without  ([uestion  and  in  ignorance  of  the 
accident.  Six  or  eight  interrupted  silver  sutures  were  needed  to 
close  the  rent ;  she  was  ])laccd  in  bed  with  the  full  expectation  on  my 
part  of  an  attack  of  peritonitis,  but  she  had  not  the  slightest  disturb- 
ance. This  accident  was  witnessed  by  the  entire  hospital  staff',  and 
by  several  others  not  connected  with  the  institution.  She  expressed 
great  satisfaction  for  the  "operation"  I  had  performed,  but  it  was  of 
little  permanent  benefit,  since  the  tumor  gradually  increased  in  size, 
and  a  few  years  afterwards  she  died  from  exhaustion.  I  succeeded, 
however,  in  diminishing  the  loss  of  blood  for  a  long  time  by  making 
a  superficial  incision  along  the  face  of  the  tumor,  as  it  presented  in 
the  uterine  canal,  extending  its  whole  length,  from  above  as  far  as  it 
could  be  reached. 

We  must  now  consider  in  a  special  manner,  and  at  some  length,  the 
different  means  to  be  employed  for  controlling  hemorrhage. 

Position  is  of  prime  importance  in  its  eff"ect  upon  uterine  hemor- 
rhages. A  woman  suffering  from  a  fibrous  growth  in  the  uterus 
should  assume  the  horizontal  position,  on  the  slightest  appearance  of  a 
show.  This  rule  should  be  rigidly  observed  notwithstanding  the  flow 
may  have  made  its  appearance  coincident  with  the  menstrual  period. 
It  is  necessary  to  do  this  that  we  may  offer  a  check  to  the  current  of 
blood  towards  the  pelvis  at  the  beginning,  and  thus  do  much  towards 
breaking  up  the  habit  of  flowing.  When  in  bed  it  is  also  advisable  to 
keep  the  feet  elevated,  so  as  to  place  the  patient  on  an  inclined  plane, 
by  which  means  the  pelvic  circulation  will  be  greatly  diminished. 
The  room  should  be  kept  cool,  and  the  patient  quiet. 

There  are  but  few  remedies,  for  internal  administration  on  whose 
direct  action,  any  reliance  can  be  placed,  and  it  is  doubtful  if  any 
would  be  effective  without  the  aid  of  both  rest  and  position. 

Ergot,  opiiim,  gallic  acid,  cinnamon,  and  sometimes  the  tincture  of 
cannabis  Indica,  are  the  agents  generally  employed  for  controlling 
hemorrhage.  A  number  of  others  are  usually  recommended,  but  they 
are  found  in  practice  to  be  of  little  value.  Ergot,  as  already  stated, 
cannot  be  relied  upon  to  arrest  a  hemorrhage,  and  I  have  frequently 
noticed  that  at  the  time  of  the  flow,  it  has  the  effect  of  rather  increas- 
ing the  quantity.  Unless  it  be  employed  for  the  purpose  of  exciting 
uterine  contraction,  it  should  be  administered  only  in  moderate  doses, 
during  the  interval  between  the  flows,  and  then  with  the  view  of  les- 
sening the  calibre  of  the  vessels,  and  so  aid  indirectly  in  reducing  the 
supply  of  blood. 

Opium  is  an  exceedingly  valuable  remedy,  since  by  allaying  the 
local  irritation,  it  quiets  the  circulation  through  the  action  of  the  sym- 


552  LOCAL    A^'D    GENERAL    TREATMENT    OF 

pathetic  system,  and  secures  contraction  of  the  capillaries,  and  a  dimin- 
ished loss  of  blood.  It  is  best  administered  by  the  rectum,  since  it 
thus  enables  a  tampon  to  be  better  borne,  and  leaves  the  stomach  for 
such  other  remedies  as  may  be  deemed  advisable. 

I  give  gallic  acid,  and  cinnamon  together  :  a  drachm  of  gallic  acid 
is  rubbed  up  in  an  ounce  of  simple  syrup,  to  ^vhich  four  ounces  of  cinna- 
mon water  and  three  of  pure  water  are  subsequently  added.  Of  this 
mixture  a  tablespoonful  is  to  be  given  every  two  or  three  hours.  If 
this  dose  should  cause  naiisea  it  may  be  still  more  diluted,  diminished 
in  quantity,  or  administered,  at  longer  intervals,  as  the  flow  becomes 
lessened.  These  two  remedies  are  more  efficacious  when  given  to- 
gether, than  either  would  be  separately,  but  their  use  is  somewhat 
empirical,  from  the  fact  that  we  have  no  very  definite  idea  as  to  their 
mode  of  action.  Gallic  acid  has  no  purely  astringent  properties,  but 
it  is  thought  by  physiologists  to  undergo  in  the  system  a  molecular 
conversion  into  tannic  acid,  and  thus  to  determine  the  contraction  of 
ultimate  fibres.  This  may  be  so,  but  the  administration  of  tannic  acid, 
on  account  of  its  primary  local  effects  on  the  alimentary  canal,  does 
not  yield  the  same  ultimate  results  as  its  congener,  although  it  is 
excreted  as  gallic  acid.  Large  doses  of  cinnamon  have  the  effect  of 
lessening  apparently  the  action  of  the  heart,  and  the  drug  may  have 
some  properties  in  common  with  ergot. 

Dr.  Churchill  and  Dr.  McClintock  both  recommend  highly  in  their 
works  the  tincture  of  cannabis  indica,  in  ien-drop  doses,  three  times 
a  day,  for  arresting  uterine  hemorrhage.  The  efficacy  of  this  remedy 
must  be  due  to  such  properties  as  it  may  hold  in  common  with  opium. 
Dr.  McClintock  has  found  some  cases  of  uterine  hemorrhage  where 
one-sixteenth  of  a  grain  of  the  bichloride  of  mercury  every  six  hours 
arrested  the  flow,  while  the  same  effect  was  produced  in  others  by 
pushing  calomel  to  the  very  verge  of  salivation. 

Opium,  gallic  acid,  and  cinnamon  may  be  useful,  and  should  always 
be  tested,  but  I  have  found  the  only  reliable  means  to  consist  in  local 
applications  and  measures.  These  are  hot  water  injections,  the  tinc- 
ture of  iodine,  for  dilatation  of  the  uterine  canal  if  necessary,  and, 
above  all,  a  tampon,  either  of  cotton  saturated  with  a  solution  of  alum, 
or  one  of  oakum.  Notwithstanding  the  hemorrhage  may  be  free,  I  do 
not  hesitate  to  place  the  patient  on  the  side,  open  the  vagina  by  means 
of  the  speculum,  and  then  ascertain  the  direction  and  curve  of  the 
uterine  canal,  by  careful  use  of  the  probe.  The  applicator  being  pro- 
perly curved,  and  a  tuft  of  cotton  twisted  about  it,  Churchill's  tincture 
of  iodine  can  be  applied  to  the  fundus.     Whenever  the  canal  is  suffi- 


FIBROUS    GROWTHS    OF    THE    UTERUS.  553 

ciently  open  for  the  ready  passage  of  the  applicator,  I  loosen  the 
cotton  in  the  manner  described  in  the  early  portion  of  this  work,  with 
the  object  of  leaving  it  behind  until  forced  out  by  the  uterus.  The 
leaving  of  this  long  strip  of  cotton  throughout  the  length  of  the  ute- 
rine canal  answers  a  double  purpose.  Its  fii-st  effect  is  to  furnish  a 
nucleus  for  the  formation  of  a  clot,  which  will  control  the  bleeding. 
At  length,  as  the  clot  becomes  too  large,  and  excites  a  sufficient  de- 
gree of  pressure,  uterine  contraction  will  be  excited,  with  effect  of 
expelling  both  cotton  and  clot  from  the  canal.  The  hemorrhage,  how- 
ever, will  have  been  arrested  by  compression  of  the  vessels  in  conse- 
quence of  the  uterine  contraction.  Sometimes  the  cotton  does  not 
excite  expulsive  efforts  enough  to  cause  its  ejection,  and  it  should  then 
be  removed  on  the  next  day  for  fear  that  it  may  again  bring  on  bleed- 
ing by  continued  irritation  of  the  mucous  membrane.  Whenever  a 
portion  of  cotton  is  thus  left  within  the  canal,  the  precaution  should 
always  be  taken  to  have  the  end  projecting  from  the  os  for  the  reasons 
already  given. 

When  a  case  is  regularly  under  treatment,  the  iodine  should  be 
injected,  for  which  we  must  give  the  proper  curve  to  the  nozzle  of  a 
hard-rubber  syringe.  Such  an  instrument  is  to  be  obtained,  holding 
about  an  ounce  of  fluid,  with  a  nozzle  some  six  or  eight  inches  in 
length.  By  smearing  the  nozzle  with  a  lit^e  grease,  and  with  the  aid 
of  a  spirit  lamp,  we  can  easily  give  it  the  proper  curve.  A  portion  of 
the  iodine  to  be  injected  can  be  drawn  up  into  the  syringe,  and  the 
nozzle  then  introduced  to  the  neighborhood  of  the  fundus,  as  a  probe 
would  be,  by  steadying  the  cervix  with  a  tenaculum.  With  care,  it  can 
be  passed  without  increasing  the  hemorrhage  or  causing  any  irritation. 
The  iodine  must  be  forced  out  very  slowly,  while  the  patient  lies  on 
the  left  side,  and  a  sponge  on  a  mass  of  cotton  must  be  placed  at  the 
OS  to  prevent  the  escape  of  iodine  over  the  vaginal  wall.  If  this  pre- 
caution be  not  taken,  the  irritation  of  the  iodine  over  a  larcce  surface 
of  the  vagina  may  cause  the  patient  much  discomfort,  and  make  it 
difficult  to  introduce  the  tampon  properly.  When  the  strength  of  the 
patient  will  admit  of  the  position,  it  is  better  to  inject  the  iodine  while 
she  is  on  the  knees  and  elbows,  with  the  os  exposed  by  the  speculum, 
and  she  should  remain  in  this  position  for  a  few  moments.  In  this 
Avay  every  part  of  the  canal  will  be  reached  by  the  iodine,  and  it  will 
have  the  eff"ect  of  causing  contraction  from  above  downward.  A  pro- 
fuse, colored,  watery  discharge  will  be  caused  for  a  short  time,  but 
the  remedy,  when  applied  in  this  manner,  has  the  effect,  almost 
always,  of  promptly  arresting  tlie  hemorrhage,  for  a  time  at  least. 


554  LOCAL    AND    GENERAL    TREATMENT    OF 

The  quantity  of  iodine  to  be  injected  must  depend  somewhat  upon  the 
size  and  length  of  the  canal,  but  under  no  circumstances  would  more 
than  a  drachm  be  needed.  When  the  long-nozzled  syringe  cannot  be 
readily  procured  a  good  substitute  can  be  made  by  using  a  flexible 
male  catheter  tied  over  the  short  nozzle  of  an  ordinary  glass  urethral 
syringe.  There  Avill  be  some  difiiculty  in  introducing  the  pliant 
catheter,  but  this  can  be  overcome  by  using  the  speculum,  and  with 
the  syringe  in  one  hand,  portion  after  portion  of  the  catheter  can  be 
passed  into  the  canal  by  means  of  a  pair  of  long  dressing  forceps. 
The  sudden  and  forcible  introduction  of  a  single  drop  of  fluid  into 
the  uterine  canal,  under  ordinary  circumstances,  may  be  attended 
with  the  most  disastrous  consequences.  But  the  danger  is  slight  here, 
since  the  uterus  is  made  more  tolerant,  and  the  canal  is  usually  more 
or  less  dilated  from  the  partial  protrusion  of  the  growth.  We  may 
however,  by  undue  violence,  set  vip  inflammation  of  the  tumor,  and 
this  condition  often  causes  an  attack  of  cellulitis  or  of  peritonitis. 

To  increase  the  action  of  the  iodine  a  basin  or  more  of  hot  water 
must  be  thrown  into  the  vagina  as  the  woman  lies  on  the  back  with 
her  hips  elevated.  The  use  of  hot  water  will  be  found  an  excellent 
agent  of  itself  if  the  proper  position  be  observed,  the  water  used  at  a 
high  temperature,  and  the  quantity  large.  A  steady  stream  of  hot 
water  thrown  into  the  vagina,  with  the  stimulus  of  the  jet  to  excite 
contraction,  and  prolonged  for  half  an  hour,  will  arrest  for  a  time 
almost  any  hemorrhage. 

The  loss  of  blood  takes  place  from  the  rupture  of  some  little  vessel 
on  the  mucous  membrane  of  the  canal  covering  the  portion  of  the 
partially  projecting  tumor.  Pressure  will  often  exert  a  most  bene- 
ficial efiect  by  reducing  the  size  and  number  of  vessels.  This  can  be 
applied  by  introducing  to  the  fundus,  on  the  point  of  the  sound,  an 
India-rubber  cot  or  bag,  and  distending  it  by  injecting  water  into  it. 
These  have  been  described  when  treating  of  sponge  tents,  and  the 
means  for  dilating  the  uterine  canal.  The  principle  is  the  same  as 
with  Barnes's  dilators,  but  the  cots  are  made  of  different  lengths,  with 
a  dilating  capacity  only  to  about  the  diameter  of  the  thumb.  The 
distinctive  feature  is  an  idea  of  my  own,  and  consists  in  the  sound 
passing  through  the  centre  of  the  dilator  in  a  tube  to  its  extremity. 
By  this  means  the  upper  end  can  be  held  at  the  fundus  while  being 
dilated  so  that  it  cannot  step  out,  and  no  power  is  lost  in  the  vagina 
as  with  other  dilators.  I  have  suggested  that  this  plan  be  applied  to 
Barnes's  dilators  as  it  would  make  them  more  useful  and  manageable. 
When  it  is  possible  to  introduce  this  bag  to  the  fundus  we  cannot  have 


FIBROTiS    GROWTHS    OF    THE    UTERUS.  555 

a  better  means  of  controlling  hemorrhage.  It  has  the  adv^antage  that 
with  its  use  the  vagina  need  not  be  so  distended  by  the  tampon, 
although  some  packing  will  be  necessary  to  prevent  the  dilator  from 
being  forced  out  of  the  canal  by  uterine  contraction.  The  dilator 
must  be  first  well  lubricated  with  soap.  Its  introduction  is  some- 
times greatly  facilitated  by  the  use  of  a  whale-bone  probe,  which  will 
more  readily  conform  to  the  irregular  course  of  the  canal.  Unless 
the  object  be  to  dilate  the  uterus,  the  India-rubber  bag  should  not  be 
distended  beyond  a  moderate  degree  by  which  the  canal  will  be  fully 
occupied,  and  at  the  same  time  a  sufficient  amount  of  pressure  will  be 
existed  to  arrest  the  bleeding.  I  do  not  wish  to  impress  the  reader 
Avith  the  belief  that  this  means  can  be  made  applicable  under  all 
circumstances.  In  theory  the  plan  is  faultless,  but  unfortunately  the 
application  is  sometimes  exceedingly  difficult.  The  canal  must  be 
somewiiat  patulous,  the  condition  of  the  patient  such  as  to  warrant  the 
manipulation,  and  it  is  necessary  that  the  attempt  should  be  made  on 
a  table,  and  with  the  aid  of  a  speculum.  A  stop-cock  or  a  clamp  to 
compress  the  tube  may  be  used  to  retain  the  water,  and  that  is  to  be 
placed  several  inches  outside  of  the  vagina  so  that  it  can  be  turned 
out  of  the  w^ay  over  the  abdomen  and  caught  under  the  napkin.  The 
continued  pressure  from  the  distension  should  not  be  kept  up  longer 
than  from  one  day  to  another.  The  water  may  then  be  allowed  to 
escape  and  the  bag  gently  withdrawn.  To  have  this  bag  distended 
by  means  of  air  instead  of  water,  would  be  preferable  in  every  respect, 
but  I  have  not  yet  devised  any  means  for  doing  so. 

Whenever  the  canal  has  been  dilated  it  is  a  good  practice  to  place 
the  patient  on  a  bed-pan,  and  with  the  finger  as  a  guide  pass  the  long 
nozzle  of  a  Davidson's  syringe,  properly  curved,  far  up  into  the 
uterine  canal  with  the  view  of  injecting  it  with  hot  water.  I  state  it 
as  the  result  of  a  long  experience,  now  extending  over  eleven  or 
twelve  years,  in  the  use  of  hot-water  injections  into  the  uterine  cavity, 
that  we  possess  no  better  means  than  this  for  arresting  bleeding  by 
exciting  contraction  in  both  the  vessels  and  uterine  tissue.  It  may 
sometimes  test  our  ingenuity  to  get  the  water  within  the  canal  when 
it  is  not  advisable  to  dilate  it  fully,  but  if  we  succeed  its  use  is  always 
satisfactory.  The  remarks  wl\ich  have  been  made  in  regard  to  the 
danger  from  injections  of  iodine,  within  the  canal  of -a  uterus  occupied 
by  a  fibrous  growth,  are  also  applicable  to  injections  of  water:  that 
they  can  be  safely  made  if  the  os  be  patulous  to  a  moderate  degree, 
and  the  water  be  injected  slowly  and  without  force. 

After  injecting  the  uterine  canal  or  the  vagina  it  is  always  advis- 


556  LOCAL    AND    GENERAL    TREATMENT    OF 

able  to  again  introduce  the  tampon,  unless  it  is  evident,  beyond 
doubt,  that  the  bleeding  has  ceased.  The  hot  water  will  cause  the 
vessels  to  contract,  but  the  pressure  of  the  tampon,  if  it  has  been 
applied  before,  may  still  be  of  service,  and  it  should  be  continued 
long  enough  for  them  to  recover  their  tone.  I  am  governed  somewhat 
by  the  condition  of  the  nervous  system  of  the  patient,  and  always 
continue  the  tampon  for  a  day  or  two  after  the  bleeding  has  ceased, 
if  she  shall  have  been  anxious  about  her  condition.  After  the  vaginal 
injection,  and  before  replacing  the  tampon,  it  will  add  very  much  to 
the  comfort  of  the  patient  to  have  the  whole  vagina  swabbed  out  with 
a  sponge  probang  saturated  with  glycerine. 

There  is  no  objection  to  the  boAvels  being  moved  daily,  but  this  is 
not  likely  to  be  the  case  so  long  as  the  tampon  is  used,  nor  can  an 
enema  be  administered  with  any  efficiency  if  the  vagina  is  fully  dis- 
tended. It  will,  therefore,  be  necessary  for  the  physician  to  make 
either  two  visits  or  to  instruct  the  nurse  to  remove  a  sufficient  portion 
of  the  tampon,  by  passing  the  finger  into  the  vagina  as  a  guide,  for 
the  use  of  the  knobbed  whalebone  stick.  The  tampon  should  thus  be 
partially  removed,  and  the  rectal  injection  administered  just  before 
the  expected  visit  of  the  physician.  He  should  be  punctual  to  his 
appointment,  since  the  danger  of  fresh  bleeding  is  greatly  increased 
by  the  exertion  attendant  upon  having  the  bowels  moved,  and  this 
cannot  be  guarded  against. 

Simpson,  I  believe,  first  divided  the  mucous  membrane  covering  the 
tumor,  by  a  superficial  incision  along  the  uterine  canal,  with  the 
object  of  arresting  the  tendency  to  hemorrhage.  The  operation  is 
frequently  attended  with  good  results,  as  it  cuts  off  some  of  the 
supply  of  blood  which  was  conveyed  to  the  tumor  through  the  divided 
vessels.  This  plan  may  be  resorted  to  now  and  then  during  the 
progress  of  the  case,  and  it  always  has  the  effect  of  exciting  the 
uterus  to  a  firmer  contraction  on  the  tumor. 

iS'^laton,  and  Baker  Brown  afterwards,  divided  the  cervix  laterally 
for  the  purpose  of  arresting  hemorrhage,  and  the  success  was  due  to 
increased  uterine  contraction.  Frequently  this  operation  allowed  the 
tumor  to  come  down  lower  in  the  organ  to  a  point  where  the  uterus 
woukl  be  excited,  to  exert  a  sufficient  force  to  cause  it  to  become 
pedunculated. 

Various  methods  have  been  resorted  to  for  the  purpose  of  removing 
or  destroying  the  tumor.  Thus  Velpeau  and  Amussat  were  the  first 
to  enucleate,  or,  by  force,  tear  these  tumors  from  their  beds.  Dr. 
Sims  has  been  a  recent  advocate  of  this  practice :    he  first  separates 


FIBROUS    ailOWTIIS    OF    THE    UTERUS.  557 

the  growth  all  around,  hy  a  stout  steel  instrument  suited  to  the  pur- 
pose, and  afterwards  removes  the  mass  in  sections  through  a  compara- 
tively small  opening. 

Dr.  Atlee,  of  Philadelphia,  instituted  the  practice  of  taking  out  a 
section  from  the  tumor  for  the  purpose  of  destroying  its  vitality,  and 
allowing  it  afterwards  to  break  down  and  come  away.  Simpson  was 
in  the  habit  of  introducing  a  portion  of  some  caustic  into  the  interior 
of  the  tumor  for  the  same  purpose. 

Sometimes  the  mucous  membrane  covering  the  tumor  is  divided 
from  its  lowest  attachment  upward,  as  far  as  can  be  reached,  and  its 
attachment  freely  separated.  Then  ergot  is  administered  in  large 
doses  to  cause  uterine  contraction,  that  the  tumor  may  be  driven  out 
of  its  bed  through  this  opening. 

Other  operators  do  not  hesitate  to  remove  any  projecting  portion  of 
a  tumor,  which  can  be  reached,  trusting  to  another  opportunity  pre- 
senting itself  for  removing  the  remainder,  or  that  it  will  ultimately 
become  disintegrated. 

All  these  different  modes  of  practice  are  attended  with  great  danger 
to  the  patient  from  blood  poisoning.  They  should  never  be  resorted 
to  therefore  except  under  some  peculiar  circumstances  and  when  it 
may  have  become  simply  a  choice  of  the  lesser  evil. 

With  my  present  experience  I  regard  the  removal  of  a  portion  only 
of  the  tumor  as  an  unwarrantable  procedure,  since  as  we  shall  see 
hereafter,  the  whole  can  be  removed  with  almost  as  much  facility  as  a 
part  and  with  less  risk. 

Case  XXX. — Early  in  the  winter  of  1863  a  woman  almost  forty 
years  of  age  was  admitted  to  the  Woman's  Hospital  with  uterine  he- 
morrhage, from  which  she  had  suffered  many  years.  She  was 
very  anaemic,  the  lower  extremities  Avere  oedematous,  and  her  complex- 
ion was  of  a  straw  color,  showing  the  cachexia  due  to  a  continued  loss 
of  blood.  With  the  aid  of  Dr.  Winston,  at  that  time  house  surgeon, 
the  uterus  was  dilated  after  some  preparatory  treatment,  for  the  pur- 
pose of  forming  a  diagnosis. 

I  found  a  large  fibrous  polypus  presenting  at  the  os,  which  I  could 
feel  was  attached  to  the  fundus,  but  a  little  in  front,  and  by  a  broad 
base. 

With  little  difficulty  the  chain  of  the  dcraseur  was  adjusted,  and 
drawn  tight  around  the  tumor,  I  was  able  to  keep  it  up  behind  by  a 
whalebone  staff  to  be  described  hereafter. 

A  mass  as  large  as  the  closed  fist  was  removed  without  difficulty  or 
bleeding.  I  introduced  the  finger  afterwards,  and  was  impressed  with 
the  completeness  of  the  operation,  the  whole  surface  being  smooth,  and 
continuous  with  the  sides  of  the  canal.     As  the  base,  although  large. 


558 


LOCAL    AXD    GENERAL    TREATMENT    OF 


-was  SO  mucli  smaller  than  the  mass  itself  I  took  it  for  granted  that  the 
whole  tumor  had  been  removed,  and  although  I  noticed  the  size  of 
the  fundus  was  out  of  proportion  to  the  rest  of  the  organ,  I  thought 
this  to  be  due  to  the  sub-peritoneal  fibroids  which  could  be  distinctly 
felt.  A  profuse  discharge  was  noticed  on  the  second  day  ;  this  soon 
became  offensive,  and  marked  symptoms  of  blood-poisoning  presented 
themselves.  Notwithstanding  frequent  vaginal  injections  of  warm 
water  were  employed,  but  little  benefit  Avas  derived  from  them,  and 
she  died  on  the  sixth  day  from  blood-poisoning. 

The  post-mortem  examination  showed  a  sloughing  mass  in  the  canal 
which  Avas  attached  by  so  small  a  pedicle  that  the  slightest  force  would 

Fi?.  96. 


Pedunculated  fibroid,  partiaUy  removed  hj  the  licraseur. 

have  removed  it.  The  condition  is  shown  in  Fig.  96,  from  a  sketch 
taken  at  the  time.  It  was  evident  that  I  had  cut  the  tumor  in  half  and 
that  the  portion  which  remained  was  buried  in  the  uterine  tissue.  The 
operation  itself  excited  uterine  contractions,  by  which  the  remaining 
portion  was  displaced.  The  tumor  became  more  and  more  peduncu- 
lated, as  it  Avas  forced  towards  the  os  uteri,  until  at  length  its  attach- 
ment Avas  reduced  so  much  as  to  cut  off  its  supply  of  blood,  and  the 
mass  began  to  slough.  'J'hc  action  of  the  uterus  Avould  have  been 
sufficient  to  have  driven  the  tumor  into  the  vagina  but  for  the  external 


FIBROUS    GROWTHS    OF    THE    UTERUS.  559 

fibroids  which  were  found  to  involve  the  uterine  tissue  enough  to  have 
caused  a  loss  of  power  and  irregular  contraction.  Her  antemic  con- 
dition rendered  lier  more  liable  to  blood-poisoning,  and  less  able  to 
resist  its  effects.  But  her  life  could  have  been  saved  if  I  had  sus- 
pected the  true  condition.  I  had  supposed  the  entire  tumor  was  re- 
moved, and  then  naturally  attributed  the  profuse  discharge  to  the 
large  healing  surface.  I  was  unable  then  to  do  more  for  her  locally 
than  to  direct  the  fre({uent  use  of  the  injections,  but  these  did  not 
enter  the  uterine  cavity.  At  the  present  day  such  a  case  would  be 
treated  by  Avashing  out  the  uterine  canal,  and  then  such  a  mass  could 
not  to  be  overlooked. 

The  study  of  this  case  was  an  instructive  lesson,  and  ultimately  led 
to  the  plan  of  treatment  which  I  shall  describe  hereafter. 

It  is  quite  as  hazardous  to  cut  into  a  projecting  mass,  since  the 
tissues  must  then  slough  away,  and  the  danger  of  blood  poisoning 
would  be  as  great  as  if  a  portion  were  removed.  The  same  objection 
must  exist  against  exciting  inflammation  within  the  structure  of  the 
tumor  by  the  use  of  the  cautery,  caustics  or  other  agents,  with  the 
view  of  bringing  about  disintegration.  No  man  possesses  the  means 
of  limiting  to  the  tumor  the  inflammatory  process  which  may  be 
established  by  this  mode  of  treatment.  A  number  of  successful  cases 
have  been  reported,  but  were  we  as  familiar  with  the  death  record  as 
we  are  with  the  result  when  the  treatment  has  been  successful,  no 
conscientious  man  would  ever  attempt  to  destroy  a  uterine  tumor  by 
disintegration. 

The  following  case  will  illustrate  the  danger  of  simply  cutting  into 
a  projecting  mass  without  any  knowledge  as  to  its  depth  or  attachment 
within  the  uterine  tissue. 

Case  XXXI. — June,  1871, 1  dilated  the  uterus  of  a  patient  in  the 
"Woman's  Hospital,  and  detected  near  the  fundus  a  soft  tumor  about 
an  inch  in  diameter  which  was  partially  pedunculated,  and  was  sup- 
posed to  have  been  the  cause  of  hemorrhage.  On  the  anterior  wall 
near  the  fundus  to  the  right  was  felt  through  the  abdominal  wall  a 
subperitoneal  fibroid  a  little  smaller  than  a  hen's  egg.  This  tumor 
seemed  to  be  on  one  side,  and  acccidental  in  its  connection  with  the 
growth  within  the  canal.  Dr.  T.  G.  Thomas,  a  member  then  of  the 
consulting  board,  was  present,  and  examined  the  case  at  my  request. 
From  its  shape  and  position  it  was  impossible  to  encircle  it  with  the 
chain  of  the  e^raseur,  and  it  was  too  soft  to  be  drawn  down  with  a 
tenaculum  sufficiently  within  reach  of  the  finger,  as  a  guide  for  its  re- 
moval. I  therefore  decided  to  destroy  it  by  cutting  open  with  a  pair 
of  scissors  the  portion  protruding,  and  I  believe  the  procedure  met 
with  Dr.  Thomas's  approval.  The  operation  was  easily  done,  and  by 
the  injection  of  iodine  the   slight  bleeding  was  promptly  arrested. 


560         LOCAL  AND  GENERAL  TREATMENT  OF 

The  discharge  was  very  profuse  after  the  third  day.  To  guard  against 
blood  poisoning  I  directed  the  nurse  to  introduce  the  nozzle  of  the 
syringe  just  Avithin  the  patulous  os,  and  gently  wash  out  the  uterine 
cavity  at  the  time  of  administering  the  usual  vaginal  injections.  This 
was  done  for  a  week  or  ten  days,  and  the  patient  was  apparently 
doing  well.  One  morning  during  the  administration  of  the  injection, 
the  patient  suddenly  complained  of  great  pain  and  discomfort.  On 
removing  a  nearly  empty  bed  pan  the  nurse  realized  that  some  serious 
accident  had  occurred,  and  I  was  sent  for.  The  patient  died  in  a  few 
days  from  a  violent  attack  of  peritonitis.  The  post-mortem  disclosed 
the  fact  that  the  sub-peritoneal  fibroid  had  become  displaced,  leaving 
a  smooth  opening  as  if  made  with  an  inch  augur,  from  the  uterine 
canal  through  the  fundus  into  the  peritoneal  cavity.  The  tumor  was 
found  lying  behind  the  uterus  in  a  bed  of  lymph.  It  was  soft,  and 
the  portion  which  had  been  imbedded  in  the  uterine  tissue  was  ragged 
and  sloughing.  Over  the  opening  through  the  fundus  the  intestines 
had  become  adherent  in  attempt  to  repair  the  injury.  At  the  time  I 
supposed  two  distinct  growths  had  existed,  and  in  their  development 
the  intervening  uterine  tissue  became  absorbed,  so  that  they  lay  in 
contact.  It  was  thought,  as  the  growth  within  the  uterine  cavity  dis- 
integrated, that  the  outer  tumor  became  involved  and  loosened  from  its 
attachments,  so  that  it  was  at  length  easily  displaced  by  the  injection. 
It  is  now  evident  to  my  mind  that  there  existed  but  a  single  tumor, 
and  I  have  met  with  other  instances  where  parts  of  the  same  tumor 
were  of  a  different  character. 

In  practice  the  question  will  present  itself  as  to  the  proper  course 
to  be  followed  in  the  treatment  of  fibro-cyst.  The  primary  fibrous 
tumor  of  the  uterus  may  become  at  length  a  secondary  matter  in 
comparison  with  the  cystic  formation  springing  from  it,  and  frequently 
it  seems  to  become  blighted  by  the  second  growth.  Fortunately  these 
cysts  develop  so  slowly  that  many  years  may  elapse  before  it  may 
become  necessary  to  interfere.  When  the  distension  finally  becomes 
so  great  as  to  demand  relief,  it  will  be  necessary  then  to  empty  these 
cysts  by  tapping. 

This  operation  is  attended,  as  a  rule,  Avith  more  risk  than  the  empty- 
ing of  an  ovarian  cyst.  The  escape  of  fluid  is  more  likely  to  excite 
peritonitis,  and  the  sac  itself  is  more  liable,  from  its  greater  degree  of 
vascularity,  to  become  inflamed  after  being  tapped.  As  a  rule,  the 
quantity  of  fluid  accumulating  in  any  one  cyst  is  smaller  than  with  an 
ovarian  tumor,- it  is,  therefore,  more  difficult  to  obtain  the  same  relief. 
The  fluid  should  be  removed,  Avhen  possible,  by  means  of  the  aspirator 
and  through  a  small-sized  canula.  The  operator  must  determine  the 
size  by  the  condition  of  the  case,  since  if  fluctuation  be  distinct,  a 
small  canula  will,  in  all  probability,  answer.     Should  the  tapping 


FIBROUS    GROWTHS    OF    THE    UTERUS.  561 

have  been  successful  in  removing  a  large  portion  of  the  fluid  much 
valuable  information  may  be  then  gained,  to  be  utilized  in  case  any 
operation  may  become  advisable.  It  will  be  proved  beyond  question, 
by  future  experience,  that  many  of  these  cases  can  be  relieved  by 
surgical  means.  If  after  tapping,  for  instance,  it  be  found  that  the 
fluid  was  contained  chiefly  in  a  single  sac,  an  exploratory  operation 
would  be  justifiable  in  case  it  should  refill.  By  opening  the  abdomen 
it  may  be  found  that  the  sac  sprung  from  a  point  around  which  a  liga- 
ture could  be  placed  so  as  to  admit  of  its  removal.  I  assisted  the  late 
Dr.  Peaslee,  some  years  ago,  in  an  operation  at  Astoria,  for  the  re- 
moval of  a  tumor  which  had  been  tapped  before,  and  was  supposed  to 
be  ovarian.  In  this  instance  the  cyst  grew  from  the  fundus  of  the 
uterus.  A  double  silk  ligature  was  passed  through  just  close  enough 
to  the  uterus  that  the  bottom  of  the  sac  would  be  obliterated  when  it 
was  tied.  The  sac  was  then  cut  off"  as  close  to  the  ligature  as  was 
deemed  safe,  and  the  abdomen  closed  as  after  ovariotomy.  This 
woman  recovered  without  bad  symptoms,  and  there  seemed  to  have 
been  no  further  development  of  the  tumor. 

Extirpatio7i  of  the  Uterus. — The  temptation  frequently  presents 
itself  to  perform  this  operation  at  the  urgent  request  of  some  long 
suff'erer,  who  has  at  length  reached  a  stage  when  life  itself  becomes 
of  little  value,  and  the  slightest  hope  for  the  future  compensates  for 
the  risk. 

To  remove  the  uterus  when  enormously  enlarged  from  a  fibrous 
growth  is  unquestionably  one  of  the  most  formidable  operations  a 
surgeon  can  be  called  upon  to  undertake.  The  degree  of  success 
which  has  so  far  attended  the  operation  offers  but  little  encouragment 
for  the  future.  M.  P^an,  of  Paris,  presented,  in  1873,  seven  recoveries 
out  of  nine  cases  where  he  removed  the  uterus  for  fibrous  growths. 
As  this  success  has  not  been  equalled  by  any  other  operator,  we  must 
suppose  it  to  have  been  accidental,  and  that  subsequently  he  himself  has 
not  been  so  fortunate,  as  already  five  years  have  elapsed  since  his 
last  report.  It  is  true  that  the  difficulties  of  execution  are  by  no 
means  so  formidable  as  were  presented  in  the  early  history  of  ovari- 
otomy, and  we  have  now  the  advantage  of  this  experience,  since  there 
is  necessarily  much  in  common  in  the  two  operations.  But  the 
removal  of  the  uterus  with  the  ovaries,  which  are  taken  away  at  the 
same  time,  is  attended  by  a  degree  of  shock  only  equalled  by  the 
most  extensive  injury  to  which  the  body  could  be  subjected.  With 
the  results  of  the  operation  in  this  country  no  surgeon  is  justified  in 
attempting  to  remove  the  uterus  for  the  growth  of  a  fibrous  tumor, 
36 


562  LOCAL    AND    GENERAL    TREATMENT    OF 

except  as  a  forlorn  hope.  The  difficulty  of  diagnosis,  however,  be- 
tween an  ovarian  tumor  and  a  fibro-cyst  are  sometimes  so  great  that 
an  operation  for  the  removal  of  the  former  may  have  become  far 
advanced  before  the  true  character  could  be  established.  Then  the 
operation  may  have  reached  a  stage  where  the  danger  would  be  less 
to  the  patient  to  remove  the  uterus.  The  uterus  has  been  removed 
under  these  circumstances,  and  frequently  through  an  error  in  diag- 
nosis, the  true  condition  being  detected  only  after  completion  of  the 
operation. 

With  a  large  solid  tumor,  the  difficulties  are  far  greater  than  would 
be  the  case  in  the  removal  of  an  enlarged  uterus  in  connection  with  a 
fibro-cyst.  The  latter  operation  approaches  nearer  to  that  for  the 
removal  of  an  ovarian  tumor,  and  the  shock  is  rarely  so  great  as  with 
a  large  fibrous  tumor.  To  guard  against  a  fatal  hemorrhage,  when 
the  tumor  is  a  lai-ge  and  solid  one,  it  is  always  necessary  to  pass  a 
stout  temporary  ligature  as  low  down  as  possible,  or  to  apply  Storer's 
clamp  before  cutting  away  the  mass.  Until  this  is  done,  no  plan  can 
be  formed  as  to  the  proper  manner  by  which  the  stump  should  be  se- 
cured. With  a  fibro-cyst,  the  lower  portion  of  the  uterus  is  often  so 
elongated  by  the  upward  traction,  that  it  forms  a  pedicle,  frequently 
not  thicker  than  that  often  found  attached  to  an  ovarian  tumor.  This 
is  to  be  secured  by  a  double  ligature  passed  as  near  to  the  vaginal 
junction  as  practicable  without  injury  to  the  bladder.  In  every 
respect  the  after-treatment  of  the  case  would  be  essentially  the  same 
as  after  the  removal  of  an  ovarian  tumor. 

Case  XXXII. — In  1874  a  v/oman  applied  to  me  at  the  Woman's 
Hospital  for  the  removal  of  a  large  ovarian  tumor.  After  a  careful 
examination,  and  on  passing  the  probe  to  the  depth  of  seven  inches 
into  the  uterus,  I  pronounced  the  case  one  of  fibro-cyst,  and  declined 
to  operate.  As  she  was  leaving  the  building,  Dr.  Sims  met  her  and 
brought  her  back  to  examine  her  as  a  matter  of  interest.  He  decided 
that  it  was  an  ovarian  tumor.  I  then  made  a  second  investigation, 
and  came  to  the  conclusion  that  Dr.  Sims' s  diagnosis  was  correct.  I 
was  the  more  confirmed  in  this  opinion  from  the  fact  that  after  many 
attempts  I  could  never  again  introduce  the  probe  to  a  greater  depth 
than  two  inches  and  a  half.  An  examination  with  the  tin'2;er  save  no 
evidence  from  the  vagina  that  the  uterus  was  enlarged,  but,  on  the 
contrary,  it  seemed  rather  under  size.  Drs.  Peaslee  and  Thomas  sub- 
sequently' saw  the  case,  and  both  regarded  it  as  an  ovarian  tumor. 
After  opening  the  abdominal  wall,  the  adhesions  were  found  to  be  so 
extensive  that  I  could  form  no  idea  of  the  character  of  the  tumor.  It 
was  tapped  and  freed  sufficiently  to  admit  of  a  more  thorough  examina- 
tion.    I  found  it  adherent  to  the  bladder,  and  alony;  the  brim  of  the 


FIBROUS    GROWTHS    OF    THE    UTERUS.  563 

pelvis  to  the  pelvic  fascia.  I  succeeded  in  separating  it  from  the 
fundus  of  the  bUidder  Avithout  rupture,  but  notwithstanding  tlie  greatest 
care  I  ruptured  the  iliac  sheath  on  tlie  right  side  in  freeing  an  adhe- 
sion. There  was  a  single  adhesion  high  up  to  the  rectum,  which  was 
in  turn  separated.  The  mass  which  remained  evidently  included  the 
uterus,  but  this  could  not  be  distinguished.  A  double  ligature  was 
passed  and  secured  at  the  base  of  the  mass.  On  making  an  examina- 
tion, I  found  that  ni}-  first  diagnosis  was  correct,  and  that  I  had  re- 
moved the  uterus  just  above  the  vaginal  junction.  The  uterus  had 
been  drawn  out  to  the  length  indicated  bj  the  passage  of  the  probe, 
but  the  canal  a  short  distance  up  made  a  sharp  curve  which  I  had 
once  by  accident  passed.  The  woman  never  rallied  from  the  opera- 
tion, and  died  in  a  few^  hours.  This  case  is  presented  to  show  the 
difficulties  sometimes  met  with  in  making  a  diagnosis  between  a  fibro- 
cyst  and  an  ovarian  tumor. 


564  SURGICAL    TREAIME^■T    01 


CHAPTER    XXIX. 

SURGICAL  TREATMENT  OF  FIBROUS  GROWTHS  OF  THE  UTERUS. 

PedTmculated  fibroids — Polypi — Ecrasenr — ^Removal  by  traction — Removal  of 
tbe  ovaries  for  profuse  hemorrliage  from  fibrous  tninors. 

Pedunculated  Fibroids. — ^Under  certain  circumstances  it  may  be 

good  practice  to  open  the  abdominal  cavity  for  the  purpose  of  remov- 
ing pedunculated  fibrous  growths  from  the  uterus,  particularly  now 
that  the  introduction  of  the  antiseptic  method  has  so  greatly  reduced 
the  risk  of  surgical  procedures. 

As  soon  as  I  should  be  able  to  satisfy  myself  of  the  existence  of  a 
sufficient  length  of  pedicle,  I  would  not  hesitate  to  perform  the  opera- 
tion, if  the  pressure  of  the  tumor  caused  great  irritation.  A  double 
silk  ligature  should  be  passed  through  the  pedicle  at  a  short  distance 
from  the  uterus,  and  properly  tied.  The  tumor  is  then  cut  away 
and  the  abdomen  closed  as  after  ovariotomy. 

A  tumor  with  a  pedicle  of  sufficient  length  to  admit  of  much  motion 
would,  by  pressing  on  the  bladder  or  rectum,  and  by  displacing  the 
uterus,  cause  more  irritation  than  even  a  larger  tumor  closely  attached. 
It  may,  by  traction,  excite  cellulitis,  or  even  peritonitis,  and  may 
cause  eflFasion  into  the  peritoneal  carity. 

Fibrous  Polypi. — We  are  now  to  consider  the  most  important 
portion  of  this  subject,  since  nature  often  attempts  to  effect  a  radical 
cure  of  fibrous  growths  by  giving  them  a  polypoid  shape.  And  ex- 
perience has  demonstrated  that  art  can  supply  no  safer  or  more  effec- 
tive method  than  that  suggested  by  nature. 

We  have  already  explained  the  method  by  Avhich  a  tumor  lying 
near  the  lining  membrane  becomes  ultimately  forced  out  of  its  bed 
into  the  uterine  ca\aty.  Fig.  96,  page  558,  represents  the  appearance 
of  this  attachment  by  a  pedicle.  This  pedicle,  or  stalk,  connecting  the 
tumor  to  the  uterus  is  formed  by  a  small  bloodvessel,  a  little  con- 
nective tissue,  and  the  lining  membrane  which  the  tumor  had  carried 
before  it.  Owing  to  peculiarity  of  structure  a  polypus  may  have  so 
short  a  pedicle  as  to  remain  in  close  contact  with  the  surface  from 


FIBROUS    GROWTHS    OF    THE    UTERUS.  565 

which  it  has  been  expelled.  Under  other  circumstances  we  will  find 
the  pedicle  drawn  out  to  a  great  length,  so  that  the  polyp  may  remain 
within  the  uterine  canal,  or  be  expelled  by  the  uterus  into  the  vagina 
without  breaking  its  connection.  I  have  seen  an  instance  of  a  fibrous 
polypus,  as  large  as  a  walnut,  hanging  out  of  the  labia,  and  connected 
w^ith  the  uterine  wall  by  an  attenuated  pedicle.  But,  as  a  rule,  the 
little  artery  by  which  it  is  nourished  becomes  at  length  so  stretched 
that  the  supply  of  blood  ceases,  and  the  tumor  then  begins  to  slough 
in  the  vagina.  This  is  a  very  frequent  termination  of  the  efforts  of 
nature  to  effect  a  cure,  and  the  mass  may  come  away  as  a  whole 
or  gradually  disintegrate.  Cases  are  occasionally  found  Avith  the 
polypus  projecting  from  the  os  uteri,  where  no  hemorrhage  has  oc- 
curred, and  often  not  even  a  leucorrhoea  has  been  noted.  In  other 
instances  the  hemorrhage  gradually  ceases  as  the  tumor  is  driven 
out  of  the  uterine  canal,  and  it  may  remain  in  the  vagina  after- 
wards Avithout  producing  irritation.  A  polypus  in  this  condition,  if 
sufficiently  nourished,  may  have  its  investing  membrane  undergo  a 
change  so  that  it  will  resemble  that  of  the  vagina. 

A  polypus  projecting  from  the  os  uteri  cannot  be  mistaken  for  any 
other  condition  than  an  inversion  of  the  uterus,  and  it  would  be  well 
for  the  reader,  in  this  connection,  to  consult  the  chapter  on  that  lesion. 

So  long  as  the  tumor  remains  within  the  uterine  cavity  no  accurate 
diagnosis  can  be  made  until  the  os  is  dilated  sufficiently  for  the  intro- 
duction of  the  finger.  The  directions  which  have  been  given  for 
dilating  the  uterus  are  sufficiently  explicit,  and  need  not  be  repeated. 

The  most  important  points  to  be  first  determined  in  regard  to  a 
polypus  are  its  position  and  size  of  pedicle.  When  the  attachment  is 
to  the  walls  of  the  uterus,  the  lower  portion,  at  least,  can  generally 
be  felt,  and  then,  with  a  knowledge  of  the  depth  of  the  canal  beyond 
this  point,  as  shown  by  the  use  of  the  probe,  the  size  of  the  base  can 
be  obtained  with  accuracy.  In  other  words,  the  base,  or  pedicle,  will 
always  extend  to  the  fundus  from  the  lowest  portion.  The  movement 
of  the  sound  in  different  directions  about  the  tumor  will  also  aid  in 
forming  the  diagnosis.  With  the  finger  of  one  hand  within  the 
uterus,  touching  the  lower  portion  of  the  base,  and  with  the  other 
over  the  abdomen,  we  can  gain  a  knowledge  of  the  size  of  the  tumor. 
When  the  attachment  of  the  polypus  is  at  the  fundus  it  may  be  very 
difficult  to  reach  it,  and  we  may  not  be  able  to  gain  any  accurate 
information  as  to  the  size  until,  at  the  time  of  the  operation,  the 
tumor  is  dragged  down  for  its  removal.     The  degree  of  rotatory 


566  SUR&TCAL    TREATMENT    OF 

motion  Avhich  can  be  given  to  the  tumor  by  the  finger  is  a  valuable 
indication  as  to  the  size  of  the  pedicle ;  of  course,  the  smaller  the 
pedicle  in  diameter  the  more  freedom  must  exist. 

For  the  operation  no  preparatory  treatment  is  necessary  beyond 
evacuating  the  contents  of  the  rectum  and  bladder.  Formerly  the 
general  practice  A^-as  to  pass  a  ligature  around  the  base  of  a  polypus, 
and  day  after  day  it  was  tightened,  generally  by  twisting,  until,  at 
length,  the  cord  vrould  cut  through  the  mass  as  it  sloughed.  Dupuy- 
tren  was  the  first  to  remove  uterine  growths  by  dividing  the  pedicle 
with  scissors,  but  the  practice  cannot  be  said  to  have  ever  come  into 
general  use,  through  fear  of  hemorrhage. 

The  removal  by  ligature  or  torsion  continued  to  be  the  practice 
until  Chassaignac  devised  the  ecraseur  for  the  removal  of  hemorrhoids, 
when  it  came  into  use  for  this  branch  of  surgery.  This  instrument 
encircles  the  mass  by  a  chain  loop  which  crushes  its  way  through 
as  the  loop  is  reduced  in  size,  and  by  lacerating  the  tissues  lessens 
the  liability  to  hemorrhage.  Afterwards  other  instruments  were 
constiTicted  on  the  same  general  principle,  a  wire  being  substituted 
for  the  chain.  This  was  done  in  consequence  of  the  difficulty  of 
applying  the  chain,  and  it  was  thought  easier  to  get  a  loop  of 
wire  around  a  tumor  within  the  uterus.  Sometimes  the  wire  loop 
could  be  managed  with  more  facility,  but  altogether  it  possessed  no 
advantage  over  a  well-made  chain.  Quite  the  contrary  in  fact,  for  I 
have  found  that  the  wire  is  more  liable  to  break  when  subjected  to 
the  same  degree  of  strain.  To  make  the  Ecraseur  better  adapted  for 
this  branch  of  surgery  it  was  afterwards  curved  to  conform  somewhat 
to  the  relation  of  the  uterus  with  the  vagina.  But  frequently  the 
tumor  within  the  uterus  would  be  so  situated  that  when  the  chain 
was  tightened  it  would  be  acting  almost  at  a  right  angle  to  the  instru- 
ment. The  effect  Avas  that  the  shorter  the  loop  became  the  greater 
would  be  the  strain,  and  the  instrument  was  frequently  broken. 

To  obviate  this  and  other  difficulties,  I  had  an  instrument  con- 
structed some  ten  or  twelve  years  ago  on  a  plan  of  my  own.  An 
important  feature  was  the  placing  of  two  or  three  joints  at  the  end  of 
the  instrument,  so  that  it  could  be  opened  straight  or  bent  upon  itself 
at  a  sharp  angle.  The  instrument  in  general  use  Avould,  under  some 
circumstances,  where  it  could  not  adjust  itself,  cut  off  a  mass  obliquely, 
but  this  could  never  occur  from  one  with  these  joints.  Instead  of  the 
chain  being  joined  to  the  ratchet  portion,  as  in  the  original  instrument, 
this  was  separated  into  two  parts,  so  that  between  them  two  flat  rods, 


FIBROUS    GROAVTIIS    OF    THE    UTERUS. 


567 


or  bands,  to  which  the  ends  of  the  chain  were  attached,  could  slide 
through  to  the  handle  where  they  were  secured  by  a  spring-catch.  The 
object  in  having  the  ends  of  the  chain  attached  to  rods  Avhich  could  be 
separated  from  the  instrument,  was  to  facilitate  the  passage  of  the 


Fis.  97. 


Emmet's  ficraseur. 


chain  around  a  tumor  when  the  latter  was  beyond  the  reach  of  the 
finger  (see  Fig.  97). 

Fig.  98  represents  a  copper  sound  with  a  small  circular  eye  in  the 
extremity,  which  may  be  made  by  bending  round  the  end  and  solder- 
ing it.  Or  an  opening  large  enough  may  be  first  made  in  the  end  of 
a  flat  piece  of  whalebone  which  has  been  soaked  in  hot  water  to  pre- 
vent splitting,  and  then  the  edges  can  be  rounded  or  smoothed  down 
into  the  shape  of  a  probe  by  using  the  sharp  edge  of  a  piece  of  glass 
recently  broken.  The  whalebone  makes  a  very  good  substitute  for 
the  copper  sound,  and  the  instrument  I  first  employed  Avas  made  of  it. 
Through  this  opening  both  ends  of  a  strand  of  catgut  is  to  be  passed 
after  including  the  chain  in  a  loop,  as  shown  in  Fig.  98,  and  should 
be  long  enough  to  reach  the  handle  of  the  instrument  w^hen  they  are 
drawn  tight.     If,  for  example,  a  polypus  be  attached  to  the  anterior 


568 


SURGICAL    TREATMENT    OF 


Fig.  98. 


portion  of  the  uterus,  the  copper  guide  should  be  first  bent  to  about 
the  proper  curve,  and  then  passed  to  the  fundus  behind  the  tumor, 

as  the  woman  lies  on  the  back  with  the 
legs  flexed.  If  the  two  ends  of  the 
cord  have  been  held  taught,  the  loop  of 
chain  will  of  course  have  been  carried 
up  to  the  same  position,  or  thej  can 
easily  be  so  by  making  traction.  The 
instrument  is  then  to  be  handed  to  an 
assistant,  who  will  hold  it  and  the  ends 
of  the  cord  out  of  way  by  moderate 
pressure  downward  against  the  peri- 
neum. The  operator  now  takes  in 
each  hand  one  of  the  rods  to  which 
the  end  of  the  chain  is  attached,  and 
after  passing  up  one  on  the  right  of 
the  tumor  and  another  on  the  left 
side,  the  two  are  to  be  brought  together 
in  front.  When  this  has  been  done, 
the  two  rods  are  brought  one  above  the 
other  and  secured  together  as  one 
piece,  by  certain  pins  and  socket  holes 
at  the  opposite  end  near  the  handle. 
After  these  have  been  properly  joined, 
the  end  is  to  be  pushed  down  the  sheath 
of  the  ecraseur.  On  the  sheath  slides  a  spring-catch,  resembling  in 
appearance  a  stop  on  a  cornet  h  piston,  and  this  slips  at  length  into 
one  of  a  number  of  holes  on  the  upper  sui-face  of  the  rods,  so  that 
they  can  be  drawn  back  until  secured  by  slipping  through  a  catch  in 
the  handle.  On  the  under  side  of  the  instrument  is  the  usual  slide  by 
which  the  ratchet  surface  becomes  fixed  and  made  ready  for  work. 
As  the  chain  is  held  up  by  the  instrument  on  the  distal  side,  it  must 
encircle  the  base,  close  to  its  attachment  all  round,  as  soon  as  it  be- 
comes tightened.  The  guide  can  then  be  removed,  and  if  the  catgut 
strand  does  not  follow  by  moderate  traction  made  on  one  end,  it  may 
be  allowed  to'  remain.  A  small  cord  would  answer,  but  the  catgut 
is  preferred,  since  this  substance  would  be  less  likely  to  catch  in  the 
joints  of  the  chain.  A  great  leverage  is  gained  at  the  handle  by  the 
construction  of  this  ecraseur  in  which  the  ratchets  are  separated. 
This  instrument  I  have  used  but  little,  from  the  fact  that  I  had  already, 


Mode  of  adjusting  the  ecrasear  chain. 


FIBROUS    GROWTHS    OF    THE    UTERUS.  569 

years  before  its  conception,  substituted  the  use  of  the  scissors  in  some 
form  for  almost  every  operation  in  this  branch  of  surgery.  The 
^craseur  is  an  efficient  instrument  for  the  removal  of  polypi,  but  not 
an  essential  one. 

After  having  satisfied  myself  that  the  case  is  not  one  of  inversion 
of  the  uterus,  I  pass  up  alongside  of  the  index  finger  a  strong  tenacu- 
lum and  then  hook  it  deeply  into  the  body  of  the  polypus.  This  will 
allow  the  operator  to  draw  down  the  tumor  with  one  hand  while  he 
retains  the  finger  of  the  other  hand  within  the  uterus.  At  length  the 
point  of  attachment  will  be  reached,  for  the  tumor  will  soon  be  forced 
lower  by  the  uterine  contractions  which  are  excited  on  making  trac- 
tion. The  assistant  is  now  to  hold  the  tenaculum,  Avhile  the  operator 
passes  up  a  pair  of  properly  curved  scissors  along  his  finger  to  the 
base  of  the  tumor,  for  the  purpose  of  dividing  the  pedicle. 

Figure  99  represents  a  steel  instrument  terminating  in  a  serrated 
edge,  which  is  to  be  placed  over  the  extremity  of  the  index  finger,  to 
take  the  place  of  the  finger  nail  in  separating  tissues. 
The  edge  catches  under  the  nail,  and  the  finger  is 
kept  from  slipping  forward  by  the  little  hood  placed 
just  behind  the  saw  to  protect  the  nail.  The  ex- 
tremity of  the  finger  below  is  left  uncovered,  so 
that  by  the  sense  of  touch  this  saw-like  surface  can 
be  directed  with  as  much  accuracy  as  if  the  finger 
nail  was  used.  I  have  never  tried  this  instrument 
with  a  cutting  surface  in  the  place  of  the  serrated 
one,  but  I  have  no  doubt  that  it  might  be  useful. 
Whenever  the  space  is  a  limited  one,  so  that  the 
finger  cannot  be  used  as  a  guide  to  direct  the  course  ™™^ 
of  the  scissors,  this  serrated  surface  can  be  employed  to  great  advan- 
tage. It  will  separate  the  tissues  as  rapidly  as  they  could  be  by  any 
other  means,  if  the  serrations  are  properly  made  and  the  parts 
are  kept  on  the  stretch.  But  it  can  be  used  for  little  more  than  divid- 
ing a  pedicle,  as  the  finger  soon  becomes  tired  and  cramped  from  the 
tight  fit  of  the  band  around  the  finger,  which  is  necessary  to  prevent 
the  instrument  from  slipping  oif.  One  rule  to  be  observed  when  the 
pedicle  is  being  divided  is,  that  if  it  is  small  in  diameter  it  may  be 
cut  through  close  to  the  uterus,  but  if  short  and  broad,  the  separa- 
tion should  be  made  near  the  tumor,  for  fear  that  a  partial  inversion 
or  indentation  may  be  caused  by  the  traction.  I  have  known  of 
two  instances  in  the  practice  of  others  where  the  uterine  wall  has 


670  SURGICAL    TREATMENT    OF 

been  perforated  from  not  appreciating  this  possibility.  Under  ordi- 
nary circumstances  it  is  not  necessary  to  remove  the  entire  pedicle,  for 
if  a  portion  is  left  it  soon  shrinks  and  disappears.  The  after-treat- 
ment will  be  described  in  the  next  chapter  while  detailing  the  history 
of  some  prominent  cases. 

Removal  of  Fibrous  G-rowtlis  from  the  Uterus  hy  Traction;  and 
After-treatment. — From  observation  I  have  come  to  the  conclusion 
that  fibrous  tumors  become  pedunculated  only  when  situated  at  a  point 
where  the  force  of  gravity  comes  into  play.  This  force  acts  as  a 
source  of  irritation  to  excite  the  muscular  fibres  of  the  uterus  to  con- 
traction. 

I  have  observed  that  the  muscular  fibres  do  not  contract  equally 
throughout  the  whole  organ.  From  some  change  of  structure,  due  in 
all  probability  to  the  long-continued  pressure  of  the  tumor,  the  fibres 
forming  the  outer  wall  of  the  uterus,  and  covering  these  growths,  lose 
to  a  great  extent  their  contractile  power.  In  corroboration  of  this 
supposition  it  has  been  noted  that  when  marked  uterine  contraction 
is  excited  an  apparent  sinking  in  of  the  sub-peritoneal  surface  fre- 
quently takes  place  to  an  extent  corresponding  to  the  interstitial 
tumor  beneath.  If  the  contraction  be  prolonged,  the  extent  of  the 
depression  will  diminish  just  in  proportion  as  the  tumor  is  forced  into 
the  uterine  canal.  About  the  circumference  of  this  neutral  space  of 
uterine  tissue,  forming  the  outer  wall  of  the  tumor,  the  muscular 
action  is  more  marked  than  at  any  other  point — a  natural  result  that 
the  greatest  action  should  be  in  proximity  to  the  seat  of  irritation. 
The  neutral  surface,  when  thus  encircled  by  a  contracting  band,  con- 
tinues to  be  crowded  in  upon  as  rapidly  as  the  space  below  becomes 
vacated,  and  the  tumor  is  pedunculated  in  proportion  to  its  advance  into 
the  uterine  canal.  This  depression  I  have  felt  distinctly  when  the 
uterus  was  in  a  state  of  active  contraction,  but  it  has  been  a  question 
in  my  mind  if  any  real  displacement  of  this  neutral  space  takes  place, 
unless  the  greater  portion  of  the  tumor  has  already  been  forced  into 
the  vagina.  I  am  rather  inclined  to  the  opinion  that  a  circular  ridge 
is  formed  by  the  damming  up,  as  it  were,  of  the  contracting  muscular 
tissue  about  this  surface,  which  thus  acts  as  an  obstruction. 

When  a  tumor  is  situated  at  or  near  the  fundus  we  can  hasten  the 
termination  of  the  case  by  exciting  contraction  in  the  muscular  fibres 
by  the  use  of  ergot,  as  is  the  accepted  practice ;  or  we  may  aid  the 
action  of  gravity  to  excite  this  uterine  contraction,  by  dilatation  of 
the  03  uteri  or  by  incising  the  cervix.     But  there  are  many  cases 


FIBROUS    GROWTHS    OF    THE    UTERUS.  571 

where  the  tumor  is  not  so  favorably  situated  in  which  the  action  of 
gravity  cannot  be  exerted,  and  where  uterine  contraction,  if  excited, 
would  be  lost  or  would  be  inert  in  displacing  the  tumor  from  its  bed. 

For  the  relief  of  a  large  number  of  these  cases  it  has  been  my 
practice  to  excite  uterine  contraction  by  making  traction  on  the  growth 
in  the  direction  of  the  uterine  outlet.  This  action  I  have  continued 
until  the  tumor  becomes  pedunculated,  from  being  crowded  out  of  its 
bed  by  muscular  contraction  closing  in  around  and  behind  the  mass. 

This  action  may  be  illustrated  by  the  removal  of  a  body  from  a 
mass  of  India-rubber.  If  the  rubber  were  stationary,  and  sufficient 
traction  were  made  by  a  tenaculum  on  the  foreign  body  buried  in  the 
mass,  the  result  would  be  similar  to  the  process  by  which  a  tumor 
becomes  pedunculated.  We  substitute  force  for  the  action  of  gravity, 
and  the  natural  contractility  of  the  substance  may  be  likened  to  the 
muscular  action  of  the  uterus.  Now,  when  this  body  is  drawn  out 
clean  from  the  mass  it  will  have  become  pedunculated,  and  no  cavity 
will  remain,  since  the  contractility  of  the  substance  was  sufficient  to 
close  in  behind  pari  passu  with  the  advance.  Therefore,  when  traction 
is  made  on  a  tumor,  with  the  effect  of  exciting  sufficient  muscular  action, 
the  space  which  was  filled  by  the  growth  will  become  immediately  ob- 
literated ;  or,  at  least,  there  will  never  remain  more  than  a  small  and 
superficial  cavity.  My  attention  has  been  directed  to  this  subject 
for  a  number  of  years,  but  the  development  of  my  views  and  practice 
to  the  present  standpoint  has  been  very  gradual. 

The  following  case  is  of  interest  as  the  starting-point  in  the  prac- 
tice, and  represents  an  important  feature  in  the  history  of  the  sub- 
ject:— 

Case  XXXIII. — In  1863  a  patient  was  admitted  to  the  Woman's 
Hospital  with  a  fibrous  tumor,  distending  the  uterus  to  its  size  at  full 
terra,  a  portion  of  which  filled  the  vagina  and  had  already  begun  to 
slough.  I  could  form  no  idea  by  a  digital  examination  as  to  its  at- 
tachments. I  applied  a  pair  of  forceps,  with  the  view  of  delivering 
the  mass  so  that  I  could  reach  its  base,  around  which  I  intended 
to  apply  the  chain  of  the  ejraseur.  My  efforts,  however,  were 
fruitless,  as  the  tumor  Avas  too  large  above  to  enter  the  pelvis.  Fear- 
ing to  leave  the  patient  in  this  condition,  I  passed,  with  the  aid  of 
Gouch's  canula,  a  stout  twine  around  the  mass,  as  high  up  as  I  could, 
within  the  uterine  cavity.  At  the  end  of  the  cord  I  made  a  slip-knot 
and  strangulated  the  mass  to  control  the  hemorrhage  which  I  antici- 
pated.  Steady  traction  was  made  on  the  cord  by  an  assistant,  for 
fear  that  hemorrhage  would  occur  should  the  noose  become  relaxed. 
I  proceeded  to  remove  the  mass,  piece  by  piece,  with  the  aid  of  a 
large  tenaculum  and  a  pair  of  properly  curved  scissors.     After  I  had 


572  suRaiCAL  treatme^^t  of 

taken  away  a  large  portion,  I  was  surprised  that  the  vagina  continued 
to  be  occupied  by  about  the  same  sized  mass  as  at  the  beginning. 
But  I  was  so  much  occupied  with  the  work  immediately  before  me, 
that  I  did  not  notice  the  gradual  decrease  in  the  size  of  the  uterus 
until  near  the  close  of  the  operation.  As  I  advanced,  the  cord  was 
cut  by  accident.  As  there  was  no  bleeding,  I  introduced  my  hand 
within  the  vagina  and  proceeded  with  the  operation  by  pulling  down 
with  the  tenaculum  portion  after  portion,  until  the  pedicle  was  reached. 
I  thus  removed  the  whole  tumor  with  scarcely  the  loss  of  an  ounce  of 
blood  after  the  traction  had  been  commenced.  I  noted  that  the  mass 
remained  blanched  in  appearance  after  cutting  the  cord,  just  as 
the  strangulated  portion  did  after  the  blood  which  it  contained  had 
escaped.  It  was  a  matter,  also,  of  the  greatest  surprise  to  me,  for 
which  I  could  offer  no  explanation,  that  the  pedicle  for  such  a  mass 
should  not  have  been  larger  in  diameter  than  the  index  finger.  Pre- 
vious to  the  operation  I  had  supposed  the  greater  portion  of  the  tumor 
was  buried  within  the  uterine  tissue.  At  the  termination  of  the  ope- 
ration the  uterine  canal  was  barely  five  inches  in  depth.  The  mass 
contained  a  number  of  cysts  of  various  sizes,  and  the  quantity  of  fluid 
which  escaped  could  not  be  estimated,  but  the  pieces  of  the  tumor 
weighed  together  nearly  seven  pounds.  The  patient  recovered  with- 
out a  bad  symptom. 

Difterent  operators  in  France  and  Germany  have  employed  the 
scissors  to  divide  the  pedicle  of  a  polypus,  but  the  chain  or  wire 
ecraseur  has  been  generallj^  used  in  Europe  and  in  this  country  for  the 
same  purpose.  The  dcraseurwas  also  employed  for  removing  as  large 
a  portion  of  a  tumor  as  could  be  included  within  the  loop  of  the  instru- 
ment, but  I  have  found  no  case  on  record  similar  to  the  above.  This 
case  seems  to  have  been  the  first  in  which  the  tumor  was  gradually 
pulled  down  and  removed,  piece  by  piece,  with  scissors  as  I  have  de- 
scribed. For  years  this  procedure  Avas  practised  only  by  myself, 
although  every  operation  had  been  witnessed,  from  time  to  time,  by 
different  members  of  the  profession.  Prof.  Wm.  T.  Howard,  of  Balti- 
more, Avas  the  first  to  put  it  into  practice  after  myself,  and  others  have 
employed  it  since.  The  success  of  the  operation  in  this  case  was 
instrumental  in  bringing  the  scissors  into  more  general  use  for  this 
branch  of  surgery. 

Case  XXXI Y, — February,  1867,  a  patient  was  admitted  to  the 
Woman's  Hospital  with  a  large  fibrous  tumor  imbedded  in  the  greater 
portion  of  the  anterior  wall  of  the  uterus.  The  tumor  encroached  on 
the  uterine  cavity,  but  only  so  far  as  to  give  a  marked  curve  to  the 
canal,  nearly  the  Avhole  mass  being  interstitial.  The  case  was  under 
the  care  of  Dr.  John  G.  Perry,  then  one  of  the  assistant  surgeons, 
who,  by  my  advice,  continued  the  use  of  sponge-tents  for  some  two 
months  or  more.     After  an  absence  of  several  weeks  she  returned  to 


FIBROUS    GROWTHS    OF    THE    UTERUS.  573 

the  hospital  in  consG(iuence  of  continued  pain  from  uterine  contraction. 
The  OS  was  found  dilated  to  some  four  inches  in  diameter,  with  the 
tumor  presenting  as  a  child's  head.  A  broad  attacliment  could  now 
be  felt  just  above  the  vaginal  junction,  somewhat  less  in  width  than 
the  portion  of  tumor  occupying  the  canal,  while  previous  to  leaving 
the  hospital  merely  a  uniform  projection  existed.  June  3,1  operated 
by  passing  well  up  into  the  canal  a  large  tenaculum,  and  by  steady 
traction  drew  down,  or  rolled  out,  into  the  vagina  a  large  portion  of 
the  mass.  I  took  out  with  a  pair  of  scissors  a  large  Avedge-shaped 
portion,  and  as  the  traction  had  already  excited  uterine  action,  I 
removed  piece  after  piece,  as  the  tumor  could  be  drawn  down,  until 
the  uterus  was  emptied.  When  the  pedicle  was  divided  it  was 
less  than  half  an  inch  in  diameter,  and  was  formed  by  the  capsule 
covering  that  portion  of  the  base  of  the  tumor  w^iich  was  nearest  to 
the  uterine  outlet  at  the  beginning  of  the  operation.  The  location  of 
the  pedicle  at  the  lowest  point,  I  have  noticed,  has  been  without  an 
exception.  I  have  referred  to  the  recorded  history  of  the  case,  and 
find  that  the  depth  of  the  uterus  was  not  noted,  but  my  impression  is 
that  it  was  eight  inches  previous  to  the  operation.  The  lower  portion 
of  the  base  was  felt  just  within  the  cervix,  and  the  attachment  of  the 
tumor  extended  from  that  point  to  the  fundus.  The  base  therefore 
could  not  have  been  less  than  seven  inches  in  length,  with  a  width  of 
from  three  to  four  inches.  I  purposely  commenced  the  traction  as 
high  up  as  possible,  and  away  from  the  lower  portion  of  the  base.  I 
excited  muscular  action  at  the  fundus,  where  it  seems  always  to  be 
greater  than  in  any  other  part  of  the  organ.  As  I  rolled  out  the 
tumor  from  above,  its  separation  advanced  from  this  point  downward 
as  the  uterus  contracted  on  the  diminishing  size  of  its  contents.  The 
portions  of  this  tumor  weighed  together  four  pounds  and  a  half. 

Case  XXXV. — A  case  similar  to  the  first  one  given  was  admit- 
ted to  the  hospital  in  1869,  in  the  service  of  Dr.  George  T.  Harrison. 
The  vagina  was  filled  by  a  portion  of  the  tumor,  which  had  begun  to 
slough,  and  the  patient  already  presented  the  symptoms  of  blood-pois- 
oning. I  used  a  cord  for  the  purpose  of  making  traction  in  the  be- 
ginning, but  afterwards  drew  down  the  tumor  as  I  have  described, 
and  removed  it  piecemeal.  The  pedicle  was  not  larger  than  the  index 
finger,  yet  previous  to  the  operation  I  am  certain  that  fully  one  third 
of  the  tumor  was  interstitial.  This  seemed  to  be  the  case,  at  least 
so  far  as  an  opinion  could  be  based  on  the  passage  of  the  sound  as 
an  indication  of  the  depth  of  the  uterine  canal.  This  tumor  was  also 
filled  with  cysts  and  their  contents  lost,  but  the  portions  removed 
weighed  a  little  over  five  pounds. 

Case  XXXVI.— March,  1874, 1  received  from  Dr.  D.  E.  Kissam, 
of  Brooklyn,  a  patient  in  my  private  hospital  who  had  long  suffered 
from  excessive  hemorrhage.  She  was  so  aniiemic  that  for  nearly  a 
month  I  carefully  controlled  the  loss  of  blood,  and  directed  my  atten- 
tion to  improving  her  general  condition  before  I  deemed  it  safe  to 


574  SURGICAL    TREATMENT    OF 

attempt  any  operative  procedure.  The  uterus  was  very  much  ante- 
verted,  enlarged  at  the  fundus,  and  somewhat  pear-shaped.  The  sound 
passed  five  inches  posteriorly  to  the  base  of  the  tumor  and  three  in- 
ches in  front  of  it.  As  soon  as  the  condition  of  the  patient  admitted 
of  doing  so,  I  dilated  the  uterine  canal  fully,  and  reached  the  lower 
portion  of  a  tumor  with  a  base  below  of  some  three  inches  in  Avidth. 
Every  other  day  I  dilated  the  canal  and  passed  high  up  within  it  an 
ergot  suppository.  One  Avas  introduced  also  into  the  rectum  every 
night,  and  on  alternate  days  in  the  morning  as  Avell  as  at  night.  These 
were  made  by  Dr.  Squibb  of  gelatine,  glycerine,  and  the  aqueous 
extract  of  ergot,  in  equivalent  to  one  hundred  grains  of  the  powder. 
Marked  uterine  contraction  followed  the  use  of  these  suppositories, 
but  the  effect  was  more  decided  when  introduced  directly  Avithin  the 
uterine  canal. 

(A  practical  point  has  been  overlooked  in  the  treatment  of  these 
cases,  should  it  be  proved  that  the  absorbing  power  of  the  uterine 
lining  membrane  is  ahvays  as  active  as  it  seemed  to  be  in  this  in- 
stance. Iodine,  for  example,  as  we  all  knoAV,  is  taken  up  so  as  to  be 
detected  by  the  taste  of  the  patient  almost  instantaneously.  This  is 
the  only  case  in  Avhich  I  have  used  these  suppositories  Avithin  the  ute- 
rus, but  do  not  think  they  could  have  acted  merely  as  a  foreign  body, 
from  the  rapidity  with  which  they  were  dissolved.) 

The  uterus  became  broader  at  the  fundus,  from  before  backward, 
and  altered  in  shape  so  much  that  a  projection  Avas  formed  on  the 
posterior  Avail  as  the  tumor  was  croAvded  in  that  direction ;  but  no 
advance  Avas  made  toward  the  uterine  outlet,  nor  did  the  base  lessen 
in  diameter.  At  the  end  of  some  ten  days  I  felt  satisfied  that  nothing 
more  could  be  gained  by  delay.  Although  the  os  beloAv  was  kept  fully 
dilated,  the  expulsive  power  was  lost,  as  in  a  shoulder  presentation. 
No  advance  could  be  made,  as,  from  the  situation  of  the  uterus  and 
the  tumor,  the  action  of  gravity  could  not  be  exerted.  I  decided  to 
remove  the  tumor  Avith  scissors,  and  placed  the  patient  under  ether ; 
but  at  the  end  of  an  hour  I  was  obliged  to  abandon  the  attempt.  I 
could  barely  reach  the  most  depending  portion  of  the  tumor  with  my 
finger,  and  failed  in  getting  a  loop  or  any  contrivance  around  the 
growth  by  Avhich  I  could  draAv  it  doAvn.  March  3d,  a  week  after,  in 
the  presence  of  Drs.  Kissam,  George  T.  Harrison,  and  Bache  Emmet, 
I  again  made  the  attempt.  I  first  retroverted  the  uterus,  and  then 
gradually  drcAV  it  doAvn  to  the  vaginal  outlet.  (When  necessary  the 
uterus  may  be  thus  brought  Avith  safety  Avithin  reach,  if  no  cellulitis 
has  existed,  and  if  the  movement  has  been  made  by  gradual  traction 
without  jerking.)  The  uterus  Avas  held  in  this  position  by  a  stout 
tenaculum  in  the  hands  of  an  assistant.  I  then  passed  the  index 
finger  Avithin  the  uterine  cavity  as  a  guide,  and  seized  Avith  a  double 
tenaculum  the  fibi-oid  high  up  posteriorly.  By  steady  traction  in  the 
course  of  half  an  hour  I  succeeded  in  draAving  a  portion  of  the  tumor 
through  the  os,  and  for  the  first  time  Avas  able  to  pass  ray  finger  around 
the  base.  The  tumor  was  a  half  spheroid  in  shape,  situated  near  the 
fundus  in  the  anterior  Avail,  about  three  inches  in  diameter  at  the  base, 


FIBROUS    GROWTHS    OF    THE    UTERUS.  576 

and  unusually  dense  in  structure.  To  give  more  room  I  removed  Avith 
the  scissors  the  portion  which  liad  been  drawn  out  from  the  os.  I 
introduced  my  hand  within  the  va;^ina  and  the  fingers  into  the  uterine 
cavity,  and  made  traction  on  the  mass  with  a  tenaculum  in  the  other 
hand.  I  requested  Dr.  Kissam  to  place  his  hand  over  the  fundus  to 
steady  the  organ  and  press  it  down  into  the  pelvis.  The  uterus  was 
now  contracting  with  great  force,  and  as  I  crowded  my  fingers  in 
around  the  base  to  aid  the  process  of  pedunculation,  if  I  may  use  the 
term,  I  could  feel  tlie  contracting  wave  passing  in  a  spiral  or  an 
oblique  direction  around  the  uterine  walls.  The  muscular  contraction 
was  more  marked  immediately  around  the  base,  as  it  seemed  to  crowd 
up  on  the  tumor.  Suddenly  Dr.  Kissam  informed  me  that  the  uterus 
was  becoming  inverted,  and  I  noticed  at  the  same  time  that  the  base 
of  the  tumor  was  lessening  in  diameter.  I  passed  my  hand  over  the 
abdomen,  and  as  the  uterus  contracted  I  could  feel  the  cup-like  de- 
pression distinctly  through  the  relaxed  abdominal  wall.  I  was  pleased 
at  the  prospect  of  the  inversion,  for  I  felt  satisfied  after  enucleating 
the  tumor  I  could  easily  replace  the  uterus.  I  therefore  redoubled 
my  efforts  to  bring  about  this  condition,  but  noticed  the  size  of  the 
depression  diminished  as  the  base  of  the  tumor  became  smaller.  This 
depi'ession  may  have  been  accidental,  or  it  may  have  been  more  marked 
in  consequence  of  the  violent  uterine  contraction,  and  in  extent  would 
necessarily  bear  a  relation  to  the  size  of  the  tumor  imbedded  beneath. 
These  are  points  Avhich  must  be  settled  by  future  observation.  But 
in  watching  this  case,  with  my  fingers  encircling  the  base  of  the  tumor, 
while  the  uterine  tissue  Avas  contracting  around  it,  I  realized  for  the 
first  time  the  manner  in  which  a  growth  becomes  gradually  pedunculated 
as  the  force  of  gravity  comes  into  play.  It  was  now  evident  to  me 
that  the  traction  Avhich  I  had  practised  for  years,  without  appreciating 
cause  and  effect,  had  produced  the  same  result.  I  also  appreciated 
that  the  uniformly  attenuated  pedicle,  which  I  had  always  noticed,  had 
been  a  natural  result  of  the  traction  I  had  employed,  and  not  acci- 
dental. Early  in  the  operation  I  called  the  attention  of  the  gentlemen 
present  to  the  appearance  of  the  portion  of  the  tumor  which  I  had 
draAvn  out  beyond  the  labia.  As  I  made  traction  to  excite  the  muscu- 
lar action  of  the  uterus,  the  mass  became  blanched,  and  remained  so 
as  long  as  the  action  Avas  kept  up.  After  the  uterus,  hoAvever,  had 
begun  to  force  the  tumor  out  of  its  bed,  this  bloodless  appearance 
became  permanent.  In  this  case,  as  is  the  rule,  the  pedicle  Avas 
formed  at  the  loAvest  point  of  the  base  nearest  to  the  uterine  outlet. 
It  Avas  unusually  small,  and  Avhen  divided  Avas  not  larger  than  an  ordi- 
nary lead  pencil,  and  yet  the  base  Avas  about  three  inches  in  diametfer 
at  the  beginning.  This  Avas  fully  appreciated  by  the  gentlemen  Avho 
assisted  me,  for  on  making  the  examination  but  a  slight  pit  or  depres- 
sion could  be  detected  Avith  the  finger  to  mark  the  point  of  attachment. 
The  operation  lasted  an  hour  and  a  half,  and  Avhen  completed  the 
uterus  was  three  inches  and  a  half  in  depth.  After  the  operation  I 
carefully  replaced  the  uterus  Avith  the  finger  to  its  normal  position  in 


576  SURGICAL    TREATMENT    OF 

the  pelvis.     This  patient  made  a  rapid  recovery,  and  two  years  later 
visited  me  in  perfect  health. 

In  the  future  history  of  the  operation  this  case  must  be  a  promi- 
nent feature,  since  it  solved  the  problem  which  I  had  been  studying 
for  ten  years.  It  at  once  placed  the  operation  on  a  scientific  basis, 
and  the  process  was  then  shown  to  be  in  accordance  with  the  laws  of 
nature. 

Case  XXXVII. — December  8,  1874,  as  I  was  about  to  commence 
my  clinic  at  the  Woman's  Hospital,  Dr.  Whitall,  the  house  surgeon, 
informed  me  that  he  had  been  obliged  to  substitute  a  patient  just  ad- 
mitted, for  operation,  whom  I  had  not  examined.  While  she  was 
being  etherized,  I  learned  that  during  her  last  labor,  three  years  pre- 
vious to  admission,  her  physician  had  been  obliged  to  remove  a  large 
growth  from  the  uterine  cavity,  which  had  obstructed  the  delivery. 
Menstruation  had  been  free,  lasting  a  week ;  and  for  a  profuse  leu- 
corrhoea,  with  a  constant  bearing  down  and  a  backache,  she  had  sought 
relief.  The  doctor  had  examined  the  case  and  reported  the  existence 
of  a  large  mucous  polypus  projecting  from  the  os  uteri.  The  specu- 
lum exposed  a  soft  vascular  growth  as  large  as  an  English  walnut, 
with  an  attachment  to  the  posterior  lip  almost  as  great.  There  had 
been  double  lateral  laceration  of  the  cervix,  and  although  this  growth 
was  outside  of  the  uterine  cavity,  it  really  sprang  from  a  surface 
which  formed  a  pai't  of  the  cervical  canal  before  the  accident.  The 
appearance  of  the  tumor  was  unusual  and  led  to  further  examination. 
I  found  the  uterus  very  wide  from  before  backward  for  its  apparent 
depth,  and  by  the  rectum  detected  a  deep  depression  near  the  fundus, 
as  if  from  inversion.  But  the  passage  of  the  sound  forward  five 
inches  indicated  the  presence  of  a  fibrous  tumor  in  the  posterior  wall, 
extending  nearly  to  the  fundus  without  encroaching  on  the  uterine 
canal.  The  growth  was  very  soft,  and  bled  profusely  in  consequence 
of  the  tenaculum  tearing  out  on  making  the  slightest  traction.  I 
therefore  resorted  to  my  favorite  means  for  the  purpose — a  cord  with 
a  slip-knot.  The  tissue  of  the  pedicle,  which  had  been  drawn  out, 
was  dense,  and  I  soon  discovered  that  it  was  inclosed  within  a  sheath 
having  an  origin  deep  within  the  uterine  Avail.  I  divided  with  the 
scissors  the  sheath  around  the  supposed  pedicle,  close  to  the  uterine 
surface,  and  proceeded  to  make  traction  as  I  separated  the  tissues 
with  my  index  finger.  I  was  soon  satisfied  that  it  was  a  portion  of 
the  fibrous  tumor  occupying  the  posterior  wall  of  the  uterus,  and 
having  advanced  so  far  I  had  no  alternative  but  to  enucleate  the  whole 
tumor.  In  the  course  of  half  an  hour  I  succeeded  in  drawing  out  a 
mass  some  four  inches  in  length,  round,  and  of  nearly  uniform  thick- 
ness throughout  of  an  inch  and  a  half  in  diameter.  In  the  beginning, 
while  making  steady  traction,  I  confined  myself  to  separating  the 
tumor  from  the  tissues  as  it  presented  itself  at  the  opening.  The 
hemorrhage  was  profuse,  and  increased  so  rapidly  when  I  had  with- 
drawn about  half  of  the  tumor,   that  I  hastened  the  operation  by 


FIBROUS    GROWTHS    OF    THE    UTERUS.  577 

introducing  ray  finger  and  breaking  up  its  attachment  in  advance. 
After  tlic  mass  had  been  removed  I  found  the  cavity  was  two  inches 
and  a  half  in  depth,  and  the  remaining  posterior  wall  of  the  uterus 
so  thin  that  I  was  surprised  it  had  not  been  ruptured.  An  equally 
thin  septum  existed  in  front,  between  the  cavity  and  the  uterine  canal, 
which  liad  not  been  entered.  The  traction  had  excited  the  muscular 
uterine  tissue  to  action,  and  the  size  of  the  organ  had  materially 
lessened ;  but  the  posterior  wall  being  so  thin,  the  contractile  force 
seemed  lost  in  that  direction.  Notwithstanding  the  depth  of  the  cavity 
had  been  shortened  an  inch  and  a  half,  it  was  my  impression  its  capacity 
had  been  but  little  diminished,  since  its  width  was  greater  than  tliat 
of  the  tumor  after  its  removal.  A  portion  of  what  seemed  to  be  a 
capsule  presented  at  the  opening,  which  I  seized  with  a  tenaculum, 
and  drawing  down  that  which  was  loose,  removed  it  Avith  the  scissors. 
The  patient  was  now  placed  on  the  back,  over  a  bed-pan,  and  the 
cavity  washed  out  Avith  a  quantity  of  very  hot  Avater,  by  means  of  a 
Davidson's  syringe.  She  Avas  afterwards  replaced  on  the  left  side, 
and  Sims's  speculum  introduced,  as  at  the  time  of  the  operation.  The 
cavity  Avas  dried  by  a  large  sponge  probang,  and  as  soon  as  it  Avas 
withdrawn,  two  drachms  of  Churchill's  tincture  of  iodine  Avas  injected. 
By  use  of  the  hot  Avater  the  size  of  the  cavity  Avas  greatly  reduced 
and  the  bleeding  diminished,  but  the  iodine  contracted  it  still  more, 
and  entirely  arrested  the  hemorrhage.  Some  pledgets  of  cotton 
saturated  Avith  glycerine  Avere  introduced  into  the  caA^ity,  now  about 
an  inch  and  a  half  in  depth,  and  the  vagina  Avas  moderately  tamponed 
Avith  cotton  dampened  Avith  a  solution  of  alum.  On  the  second  day 
after  the  operation  all  dressings  Avere  removed  and  the  cavity  care- 
fully syringed  out  Avith  Avarm  Avater,  to  Avhich  had  been  added  some 
carbolic  acid.  This  treatment  Avas  continued  from  day  to  day  Avith- 
out  a  bad  symptom  presenting,  and  the  cavity  rapidly  decreased  in 
size.  December  19th,  eleven  days  after  the  operation,  the  tempera- 
ture suddenly  rose  to  103°,  and  symptoms  of  blood-poisoning  Avere 
detected.  A  speculum  examination  Avas  made,  and  a  sloughing  mass 
exposed,  Avhich  at  first  glance  appeared  to  be  the  posterior  lip.  I 
found  that  it  Avas  a  portion  of  Avhat  had  been  thought  to  be  the  cap- 
sule protruding,  behind  Avhich  a  cyst  had  formed,  containing  about 
two  ounces  of  a  thick  gelatinous  fluid.  After  puncturing  the  cyst  I 
removed  the  remains  of  the  covering  by  means  of  scissors,  and  by 
tearing  it  aAvay  Avith  a  strong  pair  of  forceps.  There  Avas  some  bleed- 
ing, but  the  quantity  Avas  not  excessive.  Curiosity  prompted  me  to 
pass  my  finger  to  the  bottom  of  the  cavity,  Avhen  I  detected  another 
fibroid,  a  little  smaller  than  a  pigeon's  egg,  just  projecting  sufficiently 
for  me  to  map  out  its  size.  This  I  seized  Avith  a  strong  tenaculum,  and 
as  traction  Avas  made  by  Dr.  Whitall  I  cut  it  out  from  its  bed  Avith  a 
pair  of  curved  scissors.  The  uterus  contracted  promptly  on  its  re- 
moval, and  it  Avas  beyond  question  due  to  the  presence  and  position 
of  this  little  fibroid  that  the  cavity  had  not  been  more  reduced  in  size 
at  the  time  of  the  first  operation.  I  again  injected  the  iodine,  and  as 
it  excited  the  uterus  to  further  contraction  the  bleeding  Avas  entirely 
37 


578  SURGICAL    TREATMENT    OF 

arrested.  January  Tth,  I  found  the  cavity  from  which  this  tumor  had 
been  removed  now  obliterated,  and  the  uterus  three  inches  deep.  On 
the  12th  instant  she  was  discharged  from  the  hospital  cured. 

Pathologists  teach  us  that  the  dense  fibrous  tissue  which  formed 
the  mass  of  this  tumor  has  a  very  different  origin  and  history  from 
the  soft  and  vascular  growth  found  projecting  into  the  vagina,  and 
supposed  to  spring  only  from  a  mucous  surface. 

I  have  met  with  another  instance,  like  the  above  case,  where  an 
apparent  mucous  growth  merged  so  gradually  into  the  dense  tissue  of 
a  true  fibrous  tumor  that  the  contrast  could  only  be  drawn  between 
the  extremes.  And  I  think  a  third  case  might  be  claimed  in  the  one 
I  have  already  presented,  as  illustrating  the  danger  of  cutting  into  a 
growth  while  ignorant  of  its  connections.  This  case  will  be  recalled  by 
the  fact  that  the  subperitoneal  fibroid  became  detached,  leaving  an 
opening  between  the  uterine  canal  and  the  peritoneal  cavity.  In  this 
case  a  doubt  may  justly  be  advanced  as  to  the  condition  being  proved, 
for  it  is  possible  that  the  inflammatory  process  set  up  in  the  tumor, 
by  cutting  into  it,  may  have  extended  to  a  fibroid  lying  in  contact. 

But  there  can  be  no  doubt  of  the  fact  that,  in  the  other  cases,  this 
soft  tissue  was  continuous  and  sprang  from  the  fibrous  tissue.  In 
both  instances  the  specimens  were  unfortunately  lost,  so  that  no 
mici'oscopic  examination  was  made  as  to  the  true  character  of  the 
tissue. 

These  cases  seem,  in  the  absence  of  other  light,  to  indicate  that 
this  fibrous  tissue  will  sometimes  undergo  structural  changes,  depend- 
ing upon  position  and  surrounding  circumstances.  It  is,  therefore, 
probable  that  this  dense  tissue  which  had  been  long  subjected  to 
pressure  from  uterine  contraction  may,  if  freely  supplied  with  blood, 
become  in  time  entirely  changed  in  character  after  being  relieved 
from  this  pressure.  If  this  be  not  true  we  must  assume  that  the 
growth  was  sarcoma,  and  yet,  in  the  first  instance,  it  had  been  seven 
years,  and  in  the  other  nearly  four  years,  since  the  operation. 

The  mass  projecting  into  the  vagina  had,  of  course,  a  capsular 
covering  consisting  of  the  endometrium  and  a  small  quantity  of  con- 
nective tissue.  But  the  portion  of  supposed  capsule  left  in  the  cavity 
was  simply  an  outer  lamina  of  the  tumor  itself.  In  fact,  it  was  the 
appearance  of  the  tissue  in  this  case  which  first  suggested  the  doubt 
in  my  mind  as  to  the  existence  of  a  capsular  covering  for  these  tumors. 
My  opinion  now  is  that  the  tissue,  which  at  any  time  seems  to  be  a 
capsule,  may  subsequently  become  a  part  of  the  tumor  proper,  and  be 
covered  in  by  new  accretions,  if  the  mass  continues  to  grow. 


FIBROUS    GROWTHS    OF    THE    UTERUS.  579 

The  pressure,  in  this  case,  of  the  little  interstitial  fibroid  unquestion- 
ably interfered  with  and  limited  the  proper  degree  of  uterine  contrac- 
tion, so  that  quite  a  large  cavity  remained  after  the  operation.  These 
single  tumors  exercise  a  very  important  influence,  which  the  surgeon 
should  appreciate  as  fully  as  the  obstetrician.  I  am  satisfied  that  many 
cases  of  apparent  atony  of  the  uterus  and  of  irregular  action,  as  in 
the  hour-glass  contraction,  are  due  to  the  presence  of  isolated  fibroids, 
so  situated  as  to  obstruct  the  proper  contractile  action  of  the  uterine 
tissue. 

The  following  case  will  be  of  interest  in  this  connection,  and  to 
show  the  uncertainty  which  must  exist  as  to  the  depth  to  which  these 
tumors  penetrate  the  uterine  tissue. 

Case  XXXVIII. — Some  years  ago  I  assisted  Dr.  Cutter  in  Newark, 
N.  J.,  to  remove  a  large  tumor  from  the  uterus.  A  portion  of  the 
growth  presented  through  a  w^ ell-dilated  os,  and  the  lower  portion  of 
the  attachment  was  Avithin  reach  on  the  anterior  wall,  some  two  inches 
within  the  canal.  I  passed  the  chain  around  the  growth,  but  as  it 
was  being  attached  to  the  instrument  it  slipped  from  the  fingers,  and 
it  became  necessary  to  re-apply  it.  The  chain  was  again  adjusted  by 
her  physician,  and  finally  attached  to  the  ecraseur,  after  great  diffi- 
culty, from  the  fact  that  it  seemed  to  include  a  much  larger  portion 
of  the  mass  than  before.  The  hemorrhage  was  excessive  from  the 
beginning,  and  increased  to  such  an  extent  that  it  became  necessary 
to  remove  the  mass  as  rapidly  as  possible.  To  control  the  bleeding, 
ice-water  (it  being  convenient)  w^as  injected  into  the  uterine  cavity  to 
excite  contraction.  This  was  promptly  established,  but  the  bleeding 
Avas  not  arrested,  and  the  condition  of  the  patient  became  critical. 
As  soon  as  the  ecraseur  had  cut  through  and  had  been  withdrawn,  I 
passed  my  hands  within  the  uterus,  and  found  its  cavity  occupied  by 
two  tumors,  the  one  above  overlapping  the  other.  When  I  applied  the 
chain  it  passed  between  them  and  encircled  the  lower  one,  but  a  por- 
tion of  both  had  been  included  in  the  last  adjustment.  Passing  my 
hand  over  the  abdomen,  I  felt  a  sub-peritoneal  fibroid  as  large  as  a 
hen's  egg,  on  the  anterior  wall  near  the  fundus  and  to  the  left.  I  was 
satisfied  the  uterus  could  not  contract  sufficiently  to  control  the  hemor- 
rhage with  so  large  a  mass  attached  to  its  wall  and  filling  its  cavity. 
I  therefore  attempted  to  break  down  and  tear  away  with  my  fingers 
the  remains  of  the  tumors.  This  brought  on  violent  uterine  contrac- 
tion, but  irregular  in  course,  so  that  the  organ  assumed  somewhat  of 
the  hour-glass  form.  I  felt  the  canal  suddenly  encroached  upon,  and 
on  placing  my  hand  over  the  abdomen  found  the  external  tumor  had 
disappeared.  I  attempted  to  enucleate  the  presenting  mass  by  open- 
ing the  tissue  Avith  my  thumb-nail,  when  it  split,  and  the  tumor  escaped 
so  suddenly  from  its  bed  that  my  first  impression  was  that  rupture  of 
the  uterine  Avail  had  occurred.  The  uterus  noAV  contracted  uniformly 
and  rapidly,  so  that  the  remaining  masses  Avere  soon  removed,  and  the 


580  SURGICAL    TREATMENT    OF 

hemorrhage  arrested.     This  patient  convalesced  slowly  OAving  to  the 
great  loss  of  blood,  but  she  ultimately  recovered. 

I  am  satisfied  that  this  supposed  sub-peritoneal  fibroid  was  imbedded 
in  the  tissue  of  the  uterus  nearly  to  the  lining  membrane  of  its  cavity. 
Fortunately  by  the  uterine  contractions  which  were  excited,  the  tis- 
sues crowded  upon  the  tumor  so  as  to  force  it  in  the  direction  of  the 
canal,  and,  although  it  left  a  very  thin  septum  of  uterine  tissue  beneath 
the  peritoneum,  the  cavity  was  soon  closed  up  by  the  rapid  decrease 
in  the  size  of  the  uterus.  Yet  had  the  uterus  been  of  a  much  less  size 
and  this  tumor  had  become  displaced,  an  opening  would  have  remained 
between  the  uterine  canal  and  the  peritoneal  cavity. 

Had  the  portion  of  this  tumor,  lying  so  close  to  the  uterine  canal 
become  inflamed  the  whole  mass  would  have  become  loosened  with  a 
similar  result  as  the  case  previously  cited. 

I  had  already  removed  eleven  or  twelve  large  tumors  by  this 
method,  and  a  number  of  small  fibroids  without  a  fatal  result  until  the 
following  operation.  The  case  will  be  given  at  length  as  the  best 
means  of  familiarizing  the  reader  with  the  details  and  of  presenting 
the  difficulties  which  must  sometimes  be  encountered  in  this  operation. 

Case  XXXIX. — Miss  "VY.,  aged  28,  of  Bridge  water,  Vt.,  was 
admitted  to  the  Woman's  Hospital,  May  21, 18T6,  with  the  following 
history: — 

Puberty  was  established  at  the  age  of  13 ;  the  menstrual  flow  lasted 
four  days,  with  pain  during  the  first  day.  She  continued  in  good 
health  until  some  eighteen  months  ago,  wdien  the  period  became 
gradually  more  painful  throughout  the  flow,  with  an  increase  some- 
what in  quantity,  but  the  duration  remained  unchanged. 

About  eleven  months  previous  to  her  admission  she  began  to  appre- 
ciate a  feeling  of  weight  in  the  abdomen  whenever  she  suddenly  changed 
her  position  in  bed.  During  the  autumn  of  1875  she  noticed  an  increase 
in  size,  and  in  January  last  she  detected,  for  the  first  time,  a  distinct 
mass  just  above  the  pubes.  This  enlargement  increased  rapidly  in 
size  until  April  last,  when  she  consulted  Dr.  Rodiman,  her  physician, 
Avho  detected  a  fibrous  tumor.  After  the  examination  she  had  a 
hemorrhage  lasting  a  week,  ivhich  teas  the  first  and  only  abnormal 
loss  of  blood.  The  menstrual  flow  had  continued  regular  as  to  time, 
and  had  never  lasted  over  four  days.  The  increase  in  quantity  would 
not  have  been  noticed  if  her  attention  had  not  been  directed  to  it  by 
her  mother,  Avho  informed  her  that  she  used  more  napkins  than  had 
been  her  habit  when  at  her  age.  Her  physician  administered  the 
fluid  extract  of  ergot,  in  draclim  doses,  three  times  a  day,  with  the 
effect  of  arresting  the  hemorrhage,  but  the  record  of  her  case  does 
not  state  how  long  its  use  Avas  continued. 

At  my  first  examination,  I  found  the  abdomen  filled  with  a  tumor 


FIBROUS    GROWTHS    OF    THE    UTERUS.  581 

extending  above  the  umbilicus,  with  its  Lateral  diameter  the  greatest. 
The  vaginal  outlet  was  small,  as  well  as  the  vagina  itself.  The  uterus 
was  reached  high  up  in  the  pelvis,  and,  as  in  the  early  stage  of  labor, 
the  cervix  had  disappeared,  the  os  was  dilated,  its  edges  were  thin, 
and  the  tumor  presented.  The  finger  could  be  readily  introduced 
within  the  uterine  cavity,  and  the  lower  attachment  of  the  tumor  was 
felt  just  within  the  anterior  lip,  a  little  to  the  left  side,  with  a  broad 
base,  increasing  rapidly  in  width  from  below  upward.  The  uterine 
probe  was  introduced  within  the  cavity  nearly  eight  inches,  but  in  con- 
sequence of  the  great  curve  of  the  canal,  running  up  posteriorly  and 
to  the  left,  it  was  not  certain  that  the  fundus  had  been  reached. 

May  25,  at  12  j\I.,  one-half  drachm  of  the  fluid  extract  of  ergot 
was  administered,  with  the  effect  of  exciting  uterine  contraction  within 
twenty  minutes  after  it  had  been  taken.  This  dose  was  repeated  in 
the  evening,  and  three  times  on  the  26th  inst.,  with  the  effect  of  caus- 
ing no  disturbance  of  the  stomach,  but  frequent  uterine  contractions. 
May  27,  9  A.M. — The  ergot  was  omitted,  and  morphine  administered 
to  lessen  the  severity  of  the  uterine  pains ;  this  was  repeated  at  3  and 
at  9  P.  M.  Although  the  pains  had  been  frequent  and  severe  at  times, 
she  had  continued  to  go  to  her  meals  and  to  be  about  her  room  until 
bedtime  of  the  27th  inst.  She  remained  in  bed  during  the  28th  inst., 
as  the  tumor  was  advancing  into  the  vagina,  and  the  ergot  was  again 
administered  in  sufficient  doses  to  keep  up  a  moderate  degree  of  uterine 
contraction.  At  9  P.  M.,  May  28,  I  made  an  examination,  as  Dr. 
Anway,  the  house  surgeon,  had  detected,  as  he  thought,  some  odor. 
I  found  the  vagina  about  half  filled  by  the  tumor,  the  os  well  dilated, 
without  the  slightest  evidence  of  decomposition.  The  patient  com- 
plained of  feeling  tired,  but  was  cheerful,  and  I  felt  that  the  case  was 
progressing  favorably.  I  made  no  change  in  the  treatment  but  to 
discontinue  the  ergot,  and  found,  on  inquiry,  that  the  vaginal  injec- 
tions had  been  given  regularl3^  May  29,  she  was  kept  quiet  in  bed, 
and  somewhat  under  the  influence  of  morphine,  as  she  was  beginning 
to  feel  exhausted  from  the  uterine  contractions.  May  30,  in  the 
morning,  the  odor  was  marked  for  the  first  time,  and  at  2  o'clock  I 
commenced  the  removal  of  the  tumor,  after  the  patient  had  been  placed 
under  the  influence  of  ether. 

I  found  the  tumor  now  filling  up  the  whole  pelvic  canal,  and  was 
already  breaking  down  in  the  portion  presenting.  Its  shape  Avas  not 
unlike  that  of  the  cork  of  a  champagne  bottle,  the  compressed  portion 
being  in  the  pelvis  (See  Fig.  100).  I  first  attempted,  but  failed,  to 
pass  a  cord  around  the  mass  by  means  of  Gouch's  canula.  To  this  I 
wished  to  make  a  slip-knot,  to  be  used  in  making  traction  and  to  steady 
the  mass  as  it  was  being  removed. 

The  operation  was  proceeded  with  by  the  removal  of  the  mass  from 
the  vagina,  piece  by  piece,  with  the  scissors.  I  would  advance  my 
index  finger  of  the  left  hand  as  high  up  behind  the  mass  as  I  could, 
and,  while  protecting  the  soft  parts,  draw  down,  with  a  double  hook, 
some  portion  of  the  tumor  into  view.  Although  the  uterus  contracted 
promptly  from  the  beginning  of  the  operation,  and  firmly  compressed 


582 


STRGICAL    TREATMENT    OF 


the  tumor,  it  did  not  advance  into  the  vagina  as  is  usually  the  case. 
When  I  had  reached  the  plane  of  the  superior  strait,  and  the  cervix 
was  not  brought  into  view,  I  was  puzzled  as  to  the  proper  course.     I 


Fie.  100. 


Fibroas  tnmor,  projecting  in  tlie  vagina. 

profited,  however,  by  past  experience  in  realizing  that  the  danger  to 
the  patient  was  less  in  completing  the  operation  than  to  leave  a  portion 
of  the  tumor  behind  to  break  down  in  a  few  hours,  and  likely  cause 
blood  poisoning.  I  continued  to  advance  through  the  centre  of  the 
tumor  until  what  remained  was  almost  beyond  reach  of  my  instruments. 
It  became  then  necessary  to  introduce  my  hand  within  the  vagina, 
and,  in  doing  so,  the  perineum  was  partially  lacerated.  The  advance 
was  now  very  tedious,  as  the  tumor  had  been  broken  down  in  shreds, 
and  neither  the  tenaculum  or  forceps  could  grasp  but  a  small  portion 
at  a  time.  The  condition  of  the  patient  began  to  indicate  exhaustion, 
and  the  administration  of  brandy  was  commenced  by  hypodermic  in- 
jections. The  uterus  still  continued  to  contract,  and  had  been  reduced 
much  in  depth,  but  the  lateral  diameter  was  increased,  as  shown  in 
Fig.  101.  I  now  realized  how  the  expulsive  power  of  the  uterus  had 
been  lost,  and  why  the  tumor  had  not  continued  to  advance  into  the 
pelvis.  Before  the  operation  the  os  had  been  dilated  to  the  fullest 
extent  of  the  pelvic  canal,  and  as  the  tumor  came  down,  being  larger 
above,  the  lips  had  been  crowded  off  on  to  the  brim  of  the  pelvis.  This 
difficulty  was  increased  as  I  had  advanced  through  the  centre  of  the 
tumor,  for  the  expulsive  power  of  the  uterus,  being  lost  on  the  pelvic 
brim,  could  only  add  to  the  lateral  diameter. 


FIBROUS    GROWTHS    OF    THE    UTERUS. 


588 


I  placed  the  patient  on  the  left  side  and  introduced  the  largest  size 
Sims's  speculum.  Tlic  appearance  presented  hy  the  dilated  vagina, 
in  connection  with  the  excavation  which  had  heen  made  into  the  tumor, 
was  indeed  formidable.     Bj  means  of  a  large  hook,  I  drew  forward 


Fibrous  tumor,  partially  removed  (uterus  expanding-  laterally). 


the  lower  edge  of  the  tumor,  on  the  right  side,  at  A^  Fig.  101,  until  I 
brought  into  view  a  portion  of  the  surface  which  projected  into  the 
uterine  canal.  This  I  seized  with  another  hook,  and  being  the  outside 
of  the  tumor,  and  covered  with  the  lining  membrane  of  the  canal,  was 
firmer.  I  was  soon  able  to  advance  several  inches  beyond,  and, 
Avhile  steady  traction  was  made  by  Prof.  Howard,  of  Baltimore,  who 
was  then  assisting  me,  I  was  able  to  remove  with  the  scissors  a  large 
mass  which  had  lodged  on  the  brim  of  the  pelvis.  The  uterus  began 
now  to  change  rapidly  in  shape,  and  the  whole  circumference  of  the 
OS  was  brought  into  view.  By  contraction  of  the  uterus  the  remains 
of  the  tumor  were  forced  into  the  vagina  as  fast  as  the  mass  within 
reach  could  be  removed.  At  length  the  attachment  was  reached,  and 
was  found  to  have  been  reduced  to  a  pedicle  not  larger  in  size  than 
the  index  finger.  The  uterine  cavity  w^as  yet  sufficiently  dilated  to 
admit  of  partial  inversion  by  traction,  and  the  pedicle,  formed  at  the 
lowest  point  of  attachment,  just  within  the  anterior  lip,  was  divided 
in  view  at  the  labia.  The  inverted  portion  was  returned  without 
difficulty,  and  by  the  use  of  Sims's  speculum  the  Avhole  cavity  was 
brought  into  view.  By  this  means  it  was  demonstrated  that  there 
had  been  no  enucleation  of  any  portion  of  the  tumor,  and  that  the 


584  SURGICAL    TREATMENT    OF 

■whole  lining  membrane  of  the  cavity  was  intact,  except  at  the  point 
where  the  pedicle  had  been  divided.  By  contraction  the  tumor  had 
been  displaced  from  the  uterine  tissue,  and  as  it  closed  in  behind  the 
mass  its  cavity  became  lessened  until  the  extent  of  attachment,  which 
had  existed  at  the  beginning,  became  gradually  narrowed  to  but  little 
more  than  the  outer  covering  of  the  tumor,  Avhich  then  formed  the 
pedicle. 

The  cervix  was  found  very  much  discolored,  and  had  already  begun 
to  slough,  in  consequence  of  the  continued  pressure  which  the  tumor 
had  produced  on  the  brim  of  the  pelvis.  The  patient  was  placed  on 
the  back,  with  a  bed-pan  under  her,  and,  by  means  of  two  Davidson's 
syringes,  a  large  quantity  of  hot  water  was  thrown  into  the  uterine 
cavity,  with  the  effect  of  causing  rapid  contraction.  She  was  again 
placed  on  the  side,  and  the  speculum  introduced.  The  uterine  cavity 
had  now  been  reduced  to  the  depth  of  some  five  inches,  but  as  an 
additional  precaution  Churchill's  tincture  of  iodine  was  applied  to  the 
cavity  and  to  the  blackened  surface  of  the  cervix.  The  patient  Avas 
then  placed  into  bed  in  a  much  better  condition  than  she  had  been  at 
one  stage  of  the  operation,  when  her  pulse  indicated  an  approaching 
collapse.  Some  ten  drachms  of  brandy  were,  from  time  to  time,  ad- 
ministered in  small  quantities,  by  means  of  the  hypodermic  syringe. 
"Without  its  judicious  use  by  my  assistant  surgeon,  Dr.  George  T. 
Harrison,  and  Dr.  Anway,  the  house  surgeon,  1  believe  she  would 
have  sank  before  the  operation  could  have  been  completed. 

The  operation  occupied  two  hours  and  a  half,  and  the  tumor,  as 
removed,  weighed  eight  pounds,  without  estimating  the  loss  in  the 
contents  of  several  small  cysts  which  were  erupted.  The  loss  of  blood 
throughout  the  operation  was  small  in  quantity,  and  confined  almost 
entirely  to  a  small  vessel  ruptured  in  the  perineum.  Two  dense 
fibroids,  one  as  large  as  a  hen's  egg,  were  turned  out  from  the  mass, 
Fig.  100,  and  were  different  in  character  from  the  tissue  surrounding 
them.  They  had  not  yet  undergone  calcareous  degeneration,  but 
were  so  hard  that  it  was  difficult  to  cut  into  them,  and  had  evidently 
been  subjected  to  great  compression. 

An  hour  after  the  operation  the  pulse  became  weaker  and  rose  to 
175  per  minute.  She  continued  to  sink  rapidly,  soon  became  vmcon- 
scious,  and  died  nine  hours  and  a  half  after  the  operation.  She  had 
been  sweating  profusely  during  the  operation,  and  the  same  condition 
of  the  skin  continued  until  her  death. 

As  one  of  the  depressing  influences  in  her  case,  it  should  be  stated 
that,  while  she  submitted  cheerfully  to  any  treatment,  she  had  already 
become  impressed  with  the  belief  that  she  would  die.  Her  last  act, 
I  understand,  before  taking  the  ether,  was  to  designate  the  clergy- 
man whom-  she  wished  to  conduct  her  funeral.  She  certainly  was 
more  apprehensive  of  the  result  of  the  operation  than  myself. 

I  would  refer  briefly  to  some  features  in  the  history  of  this  case 
which  are  rarely  met  with,  and  are  of  importance  to  be  fully  con- 
sidered under  like  circumstances.     That  there  should  have  been  so 


FIBROUS   GROWTHS    OF    THE    UTERUS.  585 

little  menstrual  increase  from  the  growth  of  such  a  tumor  is  an  un- 
usual circumstance.  From  this  fact,  and  in  consequence  of  being  in 
such  a  perfect  state  of  health,  the  shock  of  the  operation  Avas  greater 
than  it  would  have  been  under  ordinary  circumstances.  It  is  probable 
that  the  point  had  already  been  reached  in  the  progress  of  the  case 
when  the  uterus  would  have  forced,  in  a  few  days,  the  tumor  into  the 
vagina.  It  is  also  likely  that  its  course  may  have  been  as  rapid 
without  the  aid  of  the  ergot,  and  the  same  steps  of  the  operation 
would  then  have  been  as  imperative.  Yet  the  result  in  this  case  has 
impressed  me  with  its  bearing.  In  a  like  case,  with  the  general 
health  unimpaired,  and  with  the  tumor  so  large  above,  I  should,  in  the 
future,  bring  about  a  more  gradual  dilatation,  if  it  were  possible  to 
control  the  action  of  the  uterus.  Bv  this  course  a  degree  of  toler- 
ance  may  be  established,  and  the  shock  of  the  operation  lessened. 
In  proportion  to  the  action  of  the  uterus  must  its  own  supply  of  blood 
be  lessened,  and  that  to  the  tumor  cut  off,  thus  increasing  the  danger  of 
blood-poisoning  from  sloughing  of  the  parts  most  subjected  to  pres- 
sure. In  consequence  of  the  unusual  shape  of  this  tumor  the  cervix 
was  forced  back  upon  the  brim  of  the  pelvis,  and  from  continued 
pressure  it  had  already  begun  to  slough  some  hours  before  the  portion 
of  the  tumor  presenting  in  the  vagina  gave  any  indication  of  breaking 
down.  On  the  morning  of  the  operation  there  were  symptoms  of 
blood-poisoning  detected,  which  impaired  her  powers  of  resistance 
to  the  shock  of  an  operation  unusually  prolonged  by  the  difficulties  in 
its  execution.  Yet,  guided  by  past  experience,  the  progress  of  the 
case  was  carefully  watched,  and  the  time  of  the  operation  well  chosen. 
For,  under  ordinary  circumstances,  it  is  advisable  to  dilate  rapidly,  and 
to  delay  the  operation  until  the  tumor  begins  to  break  down.  We 
thus  insure  the  greatest  amount  of  dilatation  to  be  gained,  with  the 
advantage  of  there  being  as  much  of  the  tumor  already  in  the  vagina 
as  possible  before  commencing  the  operation. 

In  concluding  the  clinical  portion  of  this  subject  I  will  present  a 
case  similar  to  the  preceding  one,  but  in  which  the  operation  was 
delayed  too  long.  I  had  previously  seen  the  case  in  consultation  with 
Dr.  S.  Whitall,  of  this  city,  and  finding  the  vagina  already  occupied 
by  a  portion  of  the  tumor,  I  urged  an  operation  withoiit  delay.  She 
had  been  flowing  almost  continuously  for  weeks,  and,  in  her  reluctance 
to  leaving  home,  she  delayed  going  to  the  Woman's  Hospital,  hoping 
that  the  flow  would  stop  of  itself  when  she  should  be  in  better  condi- 
tion. After  her  admission  the  operation  had  to  be  delayed  some  two 
weeks  more,  as  she  was  in  a  state  of  such  extreme  prostration  that 


586  SURGICAL    TREATMENT    OF 

even  a  thorough  examination  of  her  case  could  not  be  attempted. 
During  this  interval  the  flow  was  checked,  and  every  means  was 
resorted  to  to  improve  her  general  health. 

The  following  history  of  her  case  is  taken  from  the  hospital  records. 

Case  XL. — ^Mrs.  L.,  aged  28,  the  mother  of  one  child,  was 
admitted  to  Dr.  Emmet's  service  March  26,  1878. 

She  had  been  previously  a  patient  in  the  hospital  and  under  Dr. 
Sims's  care  from  Sept.  28  to  Dec.  21,  1871.  During  this  time  the 
cervix  had  been  divided,  the  covering  of  the  tumor  incised,  and  she 
had  been  kept  steadily  under  the  use  of  ergot.  But  at  the  time  of 
her  discharge  there  had  been  no  improvement,  the  uterus  was  eleven 
inches  deep  ;  as  at  the  time  of  her  admission,  the  period  still  lasted 
seven  days,  and  the  loss  of  blood  was  excessive.  This  condition  had 
then  existed  five  years. 

Since  her  discharge  from  the  hospital,  Dec.  1871,  she  had  been 
losing  large  quantities  of  blood  at  every  period,  and  requiring  the 
tampon  very  frequently,  although  she  had  continued  the  use  of  the 
ergot.  Her  appearance  was  one  of  extreme  ansemia,  the  skin  looked 
yellow  and  leathery,  she  was  very  much  emaciated,  and  looked  ten 
years  older  than  she  really  Avas. 

A  physical  examination  shoAved  that  the  fundus  of  the  uterus  reached 
nearly  to  the  umbilicus,  the  whole  organ  being  enlarged  by  a  fibrous 
tumor,  a  portion  of  which  was  projecting  into  the  vagina  and  had  the 
appearance  of  beginning  to  slough. 

She  was  flowing  at  the  time  of  admission,  and  was  ordered  to  take 
gallic  acid  and  cinnamon  Avater,  which  she  did  Avith  a  good  result. 
Extra  diet,  etc.,  ordered. 

April  7.  Began  giA'ing  thirty  minims  of  the  fluid  extract  of  ergot  by 
hypodermic  injection. 

April  9.  The  ergot  had  but  little  or  no  effect.  The  uterine  contrac- 
tions taking  place  about  half  an  hour  after  the  ergot  had  been  given, 
and  then  after  continuing  about  five  minutes  they  would  cease. 

This  morning  and  also  at  noon  six  grahis  of  ergotine  Avere  giA^en 
Avith  but  slight  effect.  The  patient  was  etherized  at  2  P.  M.  The 
sound  was  then  passed  up  eight  inches  to  the  fundus,  along  the  ante- 
rior Avail,  showing  that  the  attachment  of  the  tumor  Avas  to  the  poste- 
rior Avail.  The  os  Avas  sufiiciently  dilated  to  alloAv  of  the  escape  of 
a  portion  of  the  tumor,  about  four  inches  in  diameter. 

Dr.  Emmet  began  the  opei-ation  by  steady  traction  upon  the  pre- 
senting portion,  Avhile  an  assistant  made  pressure  on  the  fundus  above. 
After  a  large  portion  had  been  draAvn  doAvn  into  the  vagina  it  Avas  cut 
off  Avith  a  pair  of  scissors  ;  another  portion  was  then  seized  and  brought 
down,  until  at  length  the  Avhole  Avas  removed  after  a  continuous  labor 
of  three  hours. 

During  the  operation  Dr.  Emmet  was  careful  to  make  traction 
chiefly  on  that  portion  only  Avhich  projected  into  the  canal.  He  thus 
kept  as  far  as  possible   from  the  attached  portion  so  that  Avhen  the 


FIBROUS    GROWTHS    OF    THE    UTERUS.  587 

time  came  for  its  expulsion  the  uterus  would  follow  it  up  closely,  and 
thus  prevent  hemorrhage. 

Several  times  during  the  operation  the  uterus  failed  to  keep  up  a 
continuous  contraction  so  that  some  blood  was  lost. 

Hot  water  was  several  times  injected  into  the  cavity  of  the  uterus, 
with  the  effect  of  causing  instantaneous  contraction,  and  temporarily 
arresting  the  bleeding.  After  the  whole  tumor,  as  it  was  supposed, 
had  been  removed,  an  injection  was  given  to  wash  out  the  canal. 
The  effect  was  again  to  bring  on  marked  contractions,  causing  a  piece 
of  the  tumor  as  large  as  an  orange  to  be  forced  from  its  bed,  and  pre- 
sented at  the  OS.  This  was  removed  with  a  tenaculum,  and  the  uterus 
at  once  contracted  to  about  five  inches  in  depth,  so  that  the  fundus 
could  just  be  reached  with  the  finger.  The  lining  membrane  of  the 
canal  was  found  smooth,  and  when  the  patient  was  placed  on  the  side, 
with  a  speculum  in  the  usual  position,  the  interior  of  the  uterus  was 
fully  exposed  by  placing  another  speculum  within  the  cavity,  and 
under  the  arch  of  the  piibes. 

The  interior  of  the  uterus  was  thoroughly  painted  with  Churchill's 
tincture  of  iodine.  A  strip  of  cotton  saturated  with  glycerine  was  left 
in  the  canal,  projecting  from  the  os,  and  the  patient  was  then  put  to 
bed  with  vessels  of  hot  water  about  her.  She  had  become  very  much 
prostrated  from  shock,  and  a  drachm  of  brandy  was  given  hypoder- 
mically  before  the  operation  was  completed. 

April  10.  Passed  rather  a  comfortable  night,  but  vomited  occa- 
sionally, and  when  she  did  so  a  thin  watery  discharge  would  escape 
from  the  vagina.  At  9  A.M.  the  pulse  was  120,  the  number  of  res- 
pirations 32,  and  the  temperature  lOlf  °  in  the  mouth.  2  P.  M.,  P. 
118,  T.  100^°.  Thirty  minims  of  the  liq.  opii  comp.  was  given  by  the 
rectum,  as  she  was  unable  to  sleep.  7  P.  M.,  P.  110,  R.  32,  T.  102|°. 
The  tampon  was  removed  and  a  hot-water  vaginal  and  uterine  injection 
administered.  9  P.M.,  P.  110,  T.  102i°.  The  liq.  opii  comp.  was 
repeated  by  the  rectum.  During  the  day,  brandy  had  been  ad- 
ministered regularly  by  the  mouth.  At  midnight  she  began  to  sink, 
and  brandy  was  given  hypodermically.  The  same  was  repeated  at 
4  A.M.  Afterwards  the  spts.  am.  aromat.  was  administered  by  the 
same  method,  and  the  inhalation  of  the  nitrate  of  amyl  resorted  to. 
She  gradually  sank  and  died  at  7.30  A.  M. 

Afternoon  the  post-mortem  examination  was  made.  The  uterus 
was  removed  and  measured  eight  inches  in  length  by  four  inches 
Avide.  On  laying  open  the  canal  the  tissues  were  found  pale,  but  the 
mucous  membrane  was  covered  with  a  dark  bloody  secretion,  in  ap- 
pearance not  unlike  that  found  in  a  uterus  after  a  recent  labor.  At 
no  point  were  the  walls  of  the  uterus  less  than  a  quarter  of  an  inch 
in  thickness.  A  small  portion  of  the  tumor,  about  an  inch  in  diameter, 
was  found  in  the  right  horn  of  the  uterus,  and  but  slightly  adherent. 
There  was  also  a  small  fragment  still  adherent  on  the  left  side  near 
the  internal  os,  but  otherwise  the  interior  surface  was  smooth,  and 
the  tumor  had  been  entirely  removed. 

From  the  flabby  appearance  of   the  uterus  it  was  evident   that 


588  SURGICAL    TREATMENT    OF 

it  had  become  relaxed,  and  increased  somewhat  in  size  after  the 
operation.  The  portion  of  tumor  found  in  the  right  cornu  of  the 
uterus  was  an  off-shoot  which  had  been  cut  across  while  still  buried 
in  the  tissues,  but  became  nearly  detached  by  the  last  uterine  con- 
tractions. The  other  portion  near  the  internal  os  simply  indicated 
where  the  last  attachment  or  pedicle  of  the  tumor  had  been  cut  across. 

If  we  had  no  other  evidence,  the  appearance  of  the  uterus  in  this 
case  would  have  been  sufficient  to  demonstrate  fully  that  such  a  tumor 
can  be  removed  from  the  tissues  of  the  uterus,  by  the  method  de- 
scribed, without  injury  to  the  organ.  Although  this  poor  woman 
died,  the  operation  in  her  case  was  but  a  forlorn  hope  after  the  great 
loss  of  time.  The  result  would  have  been  very  different  had  she 
possessed  even  a  moderate  degree  of  strength  to  aid  in  bringing  about 
a  reaction.  The  operation  itself  was  a  complete  success  in  demon- 
strating the  principle  which  could  be  applied  in  other  cases. 

I  have  removed,  by  traction  at  least,  five  or  six  tumors  larger  than 
the  one  in  this  case,  and  a  number  of  smaller  ones,  and  but  two  deaths 
have  occurred.  That  we  may  learn  more  from  the  failures  than  from 
the  successes,  I  have  reported  at  the  greater  length  these  two  cases 
where  death  occurred. 

When  we  can  make  traction,  it  matters  little  how  thin  the  outer 
wall  of  the  uterus  may  be,  provided  we  are  able  to  excite  the  muscu- 
lar tissue  to  contraction,  since  the  space  will  be  closed  up  as  rapidly 
as  the  mass  is  withdrawn.  This  will  surely  be  the  case  when  we 
have  a  single  tumor,  especially  if  it  be  situated  near  the  fundus  or 
even  in  the  lateral  wall,  if  its  size  be  not  so  large  as  to  have  replaced 
the  greater  portion  of  the  true  uterine  tissue.  There  is  certainly  a 
limit  to  the  procedure,  but  it  is  safer  than  enucleation,  and  is  applicable 
to  every  case  where  a  prudent  operator  would  feel  justified  in  attempt- 
ing enucleation.  I  deprecate  any  effort  to  enucleate  such  a  tumor, 
from  the  fact  that  we  cannot  know  how  far  the  uterine  tissue  may 
have  become  involved.  Should  the  uterine  wall  have  become  too  thin 
to  contract  properly,  death  from  hemorrhage  would  occur  before  the 
operation  could  be  completed.  Where  muscular  action  is  not  excited 
sufiiciently,  or  to  so  limited  an  extent  as  to  leave  a  large  cavity,  as  is 
frequently  the  case  after  a  tumor  has  been  enucleated,  the  danger  is 
equally  great  of  death  from  blood  poisoning.  The  question  of  enu- 
cleation for  small  fibroids  has  no  connection  here,  since  the  circum- 
stances are  entirely  different. 

I  recommend  as  a  principle  of  practice  to  delay  all  surgical  inter- 
ference as  long  as  possible.     But  so  soon  as  the  tumor  presents  at 


FIBROUS    GROWTHS    OF    THE    UTERUS.  589 

the  OS,  and  this  begins  to  dilate,  we  then  have  proof  that  a  reasonable 
amount  of  uterine  muscular  tissue  remains  to  aid  us.  It  then  becomes 
a  question  of  judgment  as  to  the  time  and  mode  of  administering  ergot. 
As  soon  as  the  vagina  is  occupied  by  a  portion  of  the  tumor,  the  ope- 
ration for  its  removal  cannot  be  long  delayed,  for  it  becomes  then  a 
question  of  but  a  few  hours,  as  a  rule,  before  blood-poisoning  may 
supervene. 

Whenever  the  operation  has  been  once  commenced,  there  is  but  one 
course  to  follow,  in  removing  the  entire  tumor,  as  the  one  attended 
with  the  least  evil  and  risk  to  the  patient.  Whenever  the  tumor  can 
be  forced  out  by  uterine  contraction  as  rapidly  as  it  can  be  removed 
at  the  vaginal  cut,  the  operation  will  be  attended  with  but  little  risk 
of  life.  In  my  experience,  so  far,  there  has  been  no  greater  disturb- 
ance than  that  attending  any  ordinary  case  of  instrument  labor  when- 
ever the  tumor  has  been  brought  down  to  a  pedicle  and  then  divided. 
Our  purpose  is  at  first  to  excite  uterine  contraction  by  traction  on  the 
tumor,  and  this  stimulant  is  maintained  as  it  is  being  removed  piece 
by  piece  from  the  vagina.  So  that  from  the  commencement  of  the 
operation  until  the  tumor  has  become  pedunculated,  the  process  simu- 
lates a  perfectly  natural  one,  and  we  have  been  but  aiding  nature. 
As  there  is  no  fear  from  hemorrhage,  since  the  supply  of  blood  is  cut 
off  as  soon  as  the  uterus  begins  to  contract,  our  best  means  for  remov- 
ing the  tumor  is  by  a  pair  of  blunt-pointed  scissors,  curved  somewhat 
on  the  flat  side.  The  dcraseur,  I  have  found,  is  not  well  fitted  for 
the  purpose,  as  it  does  not  excite  the  uterus  to  the  proper  amount  of 
contraction,  nor  can  we  remove  the  mass  with  it  as  rapidly  as  with 
scissors.  The  operation  is  best  begun  by  passing  a  slip-knot  high  up 
around  the  mass,  which  is  to  be  held  by  an  assistant,  to  steady  the 
uterus  and  for  making  traction.  After  having  removed  the  portion 
which  first  filled  the  vagina,  it  is  best  to  follow  afterwards,  as  far  as 
possible,  the  course  of  the  uterine  canal.  The  advantage  is  twofold, 
since  the  portion  projecting  into  the  canal,  with  the  capsule-like  cover- 
ing, is  firmer,  and  by  removing  first  the  tumor  at  the  most  distant 
point,  the  line  of  attachment  becomes  narrowed  as  the  uterine  cavity 
can  be  lessened. 

A  few  words  in  relation  to  the  after-treatment.  When  the  tumor 
has  been  removed,  with  all  shreds  or  loose  portions  within  reach,  it  is 
important  to  wash  out  the  cavity  thoroughly.  It  is  best  to  use  very 
hot  water,  for  it  is  a  prompt  exciter  of  uterine  action,  and  by  prolong- 
ing the  injection  Ave  can  thoroughly  empty  all  the  capillaries  within 
reach  of  its  direct  influence.     After  the  injection  we  possess  no  better 


590  SURGICAL    TREATMENT    OF 

means  of  increasing  the  contraction,  and  of  maintaining  this  condition, 
than  in  the  free  application  of  Churchill's  strong  tincture  of  iodine. 
Should  there  be  any  oozing  of  blood  after  the  hot-water  injection,  the 
application  of  iodine  is  certain  to  arrest  it,  unless  there  exists  some 
impediment  to  the  proper  contraction  of  the  uterus.  It  is  a  most 
valuable  antiseptic,  and  I  am  confident  that  we  possess  no  better  means 
as  a  prophylactic,  when  used  as  I  have  employed  it. 

Under  no  consideration  would  I  introduce  the  persulphate  of  iron 
into  a  cavity  to  arrest  hemorrhage.  It  possesses  in  itself  no  astringent 
properties,  and  only  coagulates  a  mass  of  blood,  which  then  acts 
mechanically.  The  blood  is  so  altered  in  character  by  contact  with 
the  persulphate  that  it  undergoes  decomposition  within  a  few  hours. 
From  this  source  the  patient  frequently  becomes  blood-poisoned 
before  any  septic  element  has  been  generated  elsewhere.  It  acts  as 
a  local  irritant,  and  it  is  impossible  to  get  rid  of  it  until  removed 
by  suppuration.  After  injecting  the  iodine  I  sometimes  pack  in  a 
little  cotton  saturated  with  glycerine.  If  more  than  this  is  needed,  it 
is  better  to  use  damp  cotton  which  has  been  saturated  with  a  strong 
solution  of  alum,  and  tampon  the  vagina  with  the  same  material.  On 
the  second  day  I  carefully  remove  the  cotton,  and  if  there  is  no 
bleeding  after  washing  out  the  cavity,  I  dispense  with  all  dressings. 
It  is  necessary  to  devote  the  utmost  care  to  cleanliness  by  frequent 
injections  of  Avarm  water.  To  these  injections  may  be  added  a  little 
brewer's  yeast  as  a  stimulant  and  disinfectant,  or  carbolic  acid,  if  there 
is  any  tissue  undergoing  decomposition.  Finally  I  keep  the  patient 
in  bed  until  the  cavity  has  filled  up,  if  a  tumor  has  been  enucleated, 
or  until  all  discharge  ceases  from  the  uterine  canal,  if  a  polypus  has 
been  removed. 

The  latest  suggestion  in  reference  to  the  treatment  of  hemorrhagic 
uterine  fibroids  has  been  made  by  Dr.  "Wm.  Goodell,  of  Philadelphia.^ 
In  cases  which  are  not  amenable  to  treatment  by  the  ordinary  methods, 
he  proposes  to  remove  both  ovaries,  through  the  vagina,  if  possible, 
otherwise  by  abdominal  section.  The  operation  for  this  purpose  was 
first  performed  in  187G  by  Dr.  Trenholme,  of  Montreal,  in  one  case; 
then  by  Professor  Hegar,  of  Freiburg,  in  two  cases ;  next  by  Professor 
Nussbaura,  of  Munich,  in  one  case ;  and  lastly,  in  1877,  by  Dr.  Goodell, 
in  one  case. .  All  of  these  five  cases  were  successful,  the  symptoms 
for  which  the  operations  were  undertaken  being  wholly  relieved,  and 

1  A  Case  of  Spaying  for  Fibroid  Tumor  of  the  Womb.,  Am.  Journ.  Mi^d.  Sci., 
July,  1878. 


FIBROUS    GROWTHS    OF    THE    UTERUS.  591 

the  fibroids  themselves  shrunk  away,  as  they  sometimes  naturally  do 
after  the  menopause.  The  idea  is  that  as  the  sexual  and  periodic 
congestions  of  the  womb  feed  the  fibroids,  render  them  painful,  and 
increase  the  hemorrhage  from  them,  these  symptoms  and  the  fibroids 
themselves  ought  to  disappear  when  the  ovarian  influence  which 
causes  the  congestions  is  destroyed.  Further  experience  is  requisite 
to  establish  the  real  value  of  the  procedure. 


692      DISEASES    OF    EXTERNAL    ORGANS    OF    GENERATION. 


CHAPTER    XXX. 

DISEASES   OP  THE   EXTERNAL   ORGANS  OF  GENERATION,  CERVIX,  AND 

UTERINE  CANAL. 

Elephantiasis  and  hypertrophy  of  labia  and  clitoris — Fibrous  and  fatty  tumors — 
Oozing  tumor — Labial  cysts — Vaginismus — Vaginitis — Disease  of  the  cervix  and 
uterine  canal. 

These  are  chiefly  cancerous  growths,  from  the  mucous  membrane 
and  deeper  tissues ;  interstitial  growths  ;  and  diseases  of  the  mucous 
membrane.  Having  already  treated  of  cancerous  growths,  so  far  as 
anything  could  be  advanced  of  special  and  practical  interest,  we  need 
not  refer  again  to  them. 

We  shall  first  treat  of  elephantiasis  and  simple  enlargement  of  the 
labia,  nymphse,  and  clitoris,  fibrous  and  fatty  tumors,  cystic  growths, 
and  oozing  tumor. 

Elephantiasis  of  the  labia  is  a  very  rare  lesion  in  this  country.  In 
the  East,  where  it  is  quite  common,  much  doubt  yet  exists  as  to  its 
exciting  cause.  The  surface  is  rough,  hard,  and  dry,  and  has  little 
resemblance  to  healthy  skin.  Yirchow  regarded  the  disease  as  origi- 
nating in  the  lymphatic  glands,  the  connective  tissue  becoming  hyper- 
trophied  and  papillae  springing  up  on  the  surface.  The  rapidity  of 
growth  is  not  uniform  in  all  parts  of  the  mass,  and  that  which  develops 
first  projects  and  gives  an  irregular  appearance  to  the  surface. 

I  have  seen  but  one  instance  of  this  disease,  or  rather,  I  should 
say,  but  one  in  which  there  was  a  near  approach  to  such  a  condition, 
so  far  as  I  could  judge. 

Case  XLI. — A  woman,  from  the  western  part  of  Xew  York,  con- 
sulted me  in  April,  1866,  for  a  tumor  about  the  vulva.  She  was 
twenty-five  years  of  age,  had  been  two  years  married,  and  was  sterile. 
She  stated  that  when  between  sixteen  and  seventeen  years  old  she 
noticed  a  swelling  first  in  the  left  labium,  which  gradually  increased 
in  size.  It  occasionally  felt  sore,  but  never  really  painful.  When 
first  married  she'  suffered  a  great  deal  at  every  sexual  intercourse,  but 
she  ultimately  learned  that  if  she  turned  the  loose  tumor  up  towards 
her  stomach  no  pain  accompanied  this  act. 

The  left  labium  and  clitoris  were  enlarged  to  about  the  size  repre- 
sented in  the  wood-cut.  Fig.  102,  which  is  from  a  rough  sketch  made 
by  me  at  the  time.     The  right  labium  and  nymphje  were  in  a  healthy 


ELEPHANTIASIS    OF    THE    LABIUM. 


593 


condition,  but  the  nymphfe  on  the  left  side  had  disappeared.  The 
diseased  labium  was  rough,  hai-d,  and  like  a  piece  of  sole  leather,  while 
the  enlarged  clitoris  was  smooth  and  not  unlike  a  fibro-cystic  polypus 
in  density.     The  uterus  was  enlarged,  retroverted,  and  fixed  from  old 


Fig.  102. 


Elephantiasis  of  the  labium  and  hypertrophied  clitoris. 

cellular  inflammation.  The  cervix  was  just  within  the  vulva,  and  a 
fair  depth  to  the  vagina  had  been  gained  by  stretching  the  posterior 
cul-de-sac.  The  position  of  the  uterus  was  doubtless  the  cause  of  her 
sterility.  She  had  grown  exceedingly  nerv^ous  since  marriage,  was 
losing  flesh,  and  had  a  cough,  but  no  disease  of  the  air  passages  could 
be  detected,  except  an  old  follicular  inflammation  in  the  pharynx. 

I  advised  an  operation,  and  she  returned  home  to  consult  her  hus- 
band; he  was,  however,  unwilling  to  have  her  leave  home,  and  nothing 
was  done.     When  about  Avriting  this  chapter,  eleven  years  later,  I 
wrote  to  her  physician  for  her  after-historv,  and  learned  directly  from 
38 


59JI      DISEASES    OF    EXTERNAL    ORGANS    OF    GENERATION. 

the  woman  herself  that  there  had  been  little  increase  in  size  in  the 
growth,  and  that  her  general  health  still  remained  impaired. 

General  hypertrophy  of  the  labia  and  nymphae  occurs  from  inflam- 
mation, as  the  most  common  cause.  I  have  seen  the  nymphae  enor- 
mously enlarged  in  several  instances,  and  occasionally  so  much  so  as 
to  cause  irritation  of  the  bladder,  by  dragging  on  the  urethra.  The 
nymphse  are  easily  removed  with  scissors,  and  if  any  unusual  bleeding 
should  occur  it  can  be  controlled  by  a  compress  of  damp  cotton  over 
the  bleeding  surface,  kept  in  place  by  a  sufficiently  large  glass  vaginal 
plug.  When  this  instrument  is  used  the  compresses  need  not  be  dis- 
turbed until  loosened  by  suppuration.  The  catheter  can  be  intro- 
duced without  difficulty  while  the  plug  is  in  place,  and  at  the  same 
time  the  plug  itself  will  continue  to  exert  pressure  under  the  sym 
physis,  on  the  branch  from  the  internal  pudic  artery  which  supplies 
the  nymphse.  I  have  seen  but  a  single  instance  of  simple  hyper- 
trophy of  the  labia  to  an  extent  demanding  surgical  interference. 

Case  XLII. — The  woman  was  about  47  years  of  age,  and  had 
given  birth  to  several  children.  I  operated,  removing  both  labia,  one 
of  which  weighed  three,  and  the  other  two,  pounds.  The  edges  were 
brought  together  by  interrupted  silver  sutures,  and  union  followed  by 
first  intention.  There  seemed  to  have  been  no  apparent  local  cause 
for  this  growth,  and  I  regarded  it  simply  as  an  instance  of  excess  of 
nutrition.     There  was  no  return  of  the  disease. 

Fibrous  and  fatty  tumors  sometimes  develop  in  the  labia  to  an 
immense  size,  and  by  dragging  on  the  soft  parts  they  become  pedun- 
culated, or  rather  the  tissues  forming  their  attachment  become 
stretched  out  to  a  broad  but  thin  base. 

Case  XLIII. — About  eight  years  ago  I  was  consulted  by  a  rather 
stout  and  middle-aged  woman,  who  had  a  growth  on  the  left  labium, 
which  she  carried  in  a  bag  attached  to  her  waist.  The  tumor  was 
of  many  years'  growth,  but  she  could  not  state  with  any  certainty  the 
exact  time.  It  was  a  pure  lipoma,  or  fatty  tumor,  between  six  and 
seven  inches  long,  oval  in  shape,  and  flattened  to  about  four  inches 
in  thickness.  The  base  was  a  broad  one,  but  very  thin,  and  had  been 
so  stretched  that  the  growth  reached  nearly  to  the  knee.  As  she  lay 
on  the  back,  Avith  the  knees  and  thighs  flexed,  the  tumor  rested  between 
her  feet.  I  was  examining  the  attachment  with  great  interest,  with  a. 
view  to  an  operation  for  its  removal,  when  suddenly  she  accosted  me 
in  a  tone  calling  for  sympathy,  saying,  "And  is  it  cancer,  Doctor?" 
"Oh,  no;  you  may  rest  assured  that  it  is  nob,"  Avas  my  answer.  "I 
am  much  obliged  to  you.  Doctor;  that  is  just  what  I  wanted  to  know," 
and  down  went  the  petticoats  without  further  delay.  I  tried  to  im- 
press her  with  the  fact  that  I  had  been  hasty,  and  after  all  that 


OOZING    TUMOR    OF    THE    LABIA, 


595 


cancer  might  appear  at  her  time  of  life,  hut  ■without  any  effect,  for 
she  Avouhl  not  even  allow  me  another  examination,  that  1  might  take 
a  sketch  of  the  growth. 

Ooziric/  Tumor  of  tlie  Labia. — This  is  an  irregular  papillary,  or 
cauliflower-like,  growth  springing  from  one  or  hoth  labia,  the  promi- 
nent feature  being  a  profuse  acrid  and  watery  discharge,  which  is 
exceedingly  offensive.     It  is  supposed  to  be  due  to  a  want  of  cleanli- 

Fiff.  103. 


Oozing  tumor  of  the  labia. 


ness,  and  may  occur  at  any  age.     Those,  however,  who  have  described 
the  disease  state  it  to  be  one  of  middle  life,  most  common  with  the  fat, 


596      DISEASES    OF    EXTERNAL    ORaANS    OF    GENERATION. 


Fis.  104. 


and  with  those  who  have  borne  children.  I  have  had  but  two  cases 
under  observation.  One  was  a  young  girl,  Avhose  history  I  will  detail, 
and  the  other  was  a  young  woman,  about  twenty- three,  who  had 
never  been  pregnant.     In  both  instances  I  amputated  the  labia. 

Case  XLIV. — M.  E.  S.,  aged  16,  was  admitted  to  the  Woman's 
Hospital,  from  Oswego  Co.,  N,  Y.,  Jan.  18,  1876.  Menstruated  first 
at  twelve  ;  became  regular,  and  flow  lasted  four  days ;  but  her  general 
health  was  never  very  good.  Three  months  previous  to  admission  she 
noticed  something  growing  about  the  vulva.  This  growth  had  rapidly 
increased,  being  accompanied  by  a  very  disagreeable  discharge ;  it 
bled  readily,  but  was  free  from  pain. 

I  found  the  labia  entirely  covered  by  a  growth,  with  the  exception 
of  a  small  portion  at  the  upper  part,  which  was  very  much  swollen. 
This  growth  resembled  cauliflower  excrescence  somewhat,  and  ex- 
tended a  little  beyond  the  anus.     It  was  about  an  inch  and  a  half  in 

width  at  the  widest  part,  and  an  inch  in 
depth  (see  Fig.  101).  .  On  rolling  out  the 
parts  it  was  found  to  extend  within  but  a 
short  distance  upon  the  mucous  membrane. 
Under  the  cut  edges  of  the  mass  were  found 
several  detached  growths,  springing  from  the 
skin.  The  growth  could  be  separated  by  the 
fingers  into  distinct  lobes,  each  springing  from 
a  separate  pedicle,  but  branching  out  so  as 
to  present  on  the  surface  a  continuous  growth, 
like  the  fastigiate  cymes  of  certain  umbel- 
liferous plants,  and  tilling  the  whole  space 
between  the  thighs.  On  a  careful  examina- 
tion separate  papillte  could  be  distinguished, 
about  one-thii-d  of  an  inch  in  length,  and  all 
^  ^_  _,  ^  -fijM^sra  closely  packed  together.  An  attempt  has 
V->^y  ""  - '  ^Tr^^^^®  been  made  in  Y\^.  105  to  show  the  structure 
V.  ^i.^  -^  .  -tfMMiiffW7  of  this  growth.  Her  general  condition  was 
poor,  and  she  was  found  to  be  extremely 
anemic.  The  odor  was  excessively  fetid, 
annoying  all  about  her  in  the  ward.  Much 
time  was  spent  after  her  admission  in  keep- 
ing the  parts  as  clean  as  possible,  by  fre- 
quent washings  with  a  solution  of  carbolic 
acid  in  water. 

Jan.  25.  She  was  etherized  for  the  pur- 
pose of  being  operated  on.  Fearing  exces- 
sive hemorrhage,  I  took  a  section  of  silver 
wire,  and  attaching  a  straight  needle  directly 
to  each  end  of  the  wire,  the  tumor  being  lifted  up  from  the  parts  below 
by  an  assistant,  I  passed  each  needle  in  opposite  directions,  side  by 
side,  along  the  same  tract,  making  a  shoemaker's  stitch.  This  was 
done  at  intervals  of  one  inch.     The  left  labium  was  then  rapidly  cut 


Structure  of  oozing  tumor. 


LABIAL    CYSTS.  597 

away,  with  a  pair  of  scissors,  well  into  the  healthy  tissue.  The 
sutures  controlled  the  bleeding  to  a  great  extent,  but  it  was  necessary 
to  tie  several  arteries,  and  as  this  involved  the  removal  of  several 
of  the  sutures  to  admit  of  the  ligatures  being  tied,  some  hemorrhage 
followed.  This  determined  me  to  remove  the  other  labium  in  a  dif- 
ferent manner.  Beginning  from  above,  I  cut  through,  with  a  knife, 
about  one-third  of  the  part,  then  rapidly  introduced  the  sutures  so  as 
to  catch  up  the  skin  only,  on  opposite  sides.  These  were  then  crossed 
by  an  assistant,  and  held  down  tight  enough  to  bring  the  sides  in 
contact.  This  plan  was  followed  until  I  had  removed  the  whole. 
Yet,  notwithstanding  the  precaution,  and  the  rapidity  with  which  the 
operation  Avas  advanced,  the  loss  of  blood  was  very  great.  Contrary 
to  the  rule,  a  number  of  arteries  had  to  be  tied,  and  the  oozing  was 
troublesome.  Eleven  sutures  were  placed  in  the  left,  and  sixteen  in 
the  right,  labium.  These  sutures  were  bent  over  so  as  to  lie  flat  on 
the  skin,  and  under  their  edges  was  placed  a  narrow  strip  of  greased 
linen.  A  linen  compress  was  placed  between  the  labia,  so  as  to  keep 
up  pressure  on  each  side,  and  over  all  a  T  bandage.  The  several 
detached  points  of  growth  Avere  removed  with  scissors,  and  their  base 
touched  with  the  galvanic  cautery,  which  at  once  stopped  all  bleeding. 

There  was  nothing  in  the  progress  of  the  case  to  note  until  Feb. 
1st,  when  the  sutures  were  removed.  There  had  been  no  pain,  and 
but  little  discharge.  It  was  found  that  the  wound  itself  had  healed 
throughout  by  first  intention,  but  the  course  of  several  of  the  sutures 
was  inflamed  as  if  these  sutures  had  been  disturbed.  After  washing 
off"  the  surface,  by  squeezing  upon  it  tepid  water  from  a  sponge,  a 
daily  dressing  was  made  of  balsam  of  Peru  spread  on  linen. 

Feb.  10.  Nearly  all  the  surface  had  healed,  except  at  two  or  three 
points,  where  the  granulations  were  large,  and  these  were  touched  with 
nitrate  of  silver.  I  then  directed  the  parts  to  be  kept  dry  by  dusting 
oxide  of  zinc  over  them,  and  to  dispense  with  all  bandages,  which 
w^ere  keeping  the  parts  too  warm. 

March  1.  The  tract  of  two  sutures  had  not  yet  healed,  but  after 
making  two  applications  to  them  of  strong  carbolic  acid,  they  closed 
in  a  few  days. 

From  the  date  of  her  admission  the  greatest  care  was  directed 
towards  improving  her  general  state,  for  she  was  very  ansemic,  and 
her  appearance  improved  greatly  after  taking  an  old  preparation  of 
the  tincture  of  the  chloride  of  iron.  The  uterus  was  retroverted,  and 
there  was  quite  a  vaginal  discharge.  The  uterus  was  put  in  place, 
and  a  pessary  fitted.  Vaginal  injections  of  warm  Avater  were  freely 
used,  some  chloride  of  ammonium  being  added  to  each. 

May  12.  She  was  discharged  cured,  and  a  no  less  remarkable 
feature  in  her  case  was  the  rapidity  with  which  all  traces  of  the  ope- 
ration were  disappearing. 

Labial  Cysts. — Mucous  glands  in  a  state  of  cystic  degeneration, 
and  dermoid  cysts  are  sometimes  found  in  the  labia.  The  dermoid 
cysts  are  exceedingly  rare.     Those  of  the  labial  glands  are  formed 


598      DISEASES    OF    EXTERNAL    ORGANS    OF    GENERATION. 

by  degeneration  of  the  glands  of  Bartliolini  (also  called  glands  of 
Duvemey),  which  are  situated  on  each  side  of  the  entrance  to  the 
vagina.  These  cysts  may  form  either  in  the  glands  or  in  their  excre- 
tory ducts,  and  are  more  frequently  found  on  the  left  side.  I  have 
had  six  cases  in  private  practice  and  three  in  the  Woman's  Hospital, 
of  which  eio-ht  were  on  the  left  and  one  on  the  right  side.  All  the 
women  were  under  thirty  years  of  age,  and  the  cysts  were  found 
among  all  classes,  unmarried,  sterile,  and  fruitful.  They  develop 
very  slowly,  are  free  from  pain,  and  give  no  inconvenience  beyond 
that  which  comes  from  their  bulk.  I  have  never  seen  one  of  these 
cysts  enlarge  beyond  the  size  of  a  hen's  egg,  although  they  sometimes 
reach  a  much  larger  size. 

Diagnosis. — As  a  cyst  enlarges,  it  rolls  out  and  exposes  the  more 
delicate  mucous  membrane  covering  the  inner  face  of  the  vulva  on  that 
side,  and  its  form,  when  distended  with  fluid,  can  be  easily  defined. 
These  cysts  are  sometimes  oval,  and  it  might  be  possible,  from  a  hasty 
examination,  to  mistake  a  loosely  filled  sac  for  an  inguinal  hernia. 
Should  the  intestines  have  come  down  into  the  labium,  and  the  patient 
be  made  to  cough  while  the  mass  is  grasped  with  the  hand,  a  corre- 
sponding impulse  would  be  transmitted.  If  it  is  a  hernia,  it  can  be 
easily  reduced,  and  the  mass  will  disappear,  which  of  course  could 
not  occur  if  it  Avere  a  cyst.  Then  if  it  were  an  irreducible  hernia 
without  being  strangulated,  the  gut  would  always  be  sufficiently  dis- 
tended by  flatus  to  give  a  clear  sound  on  percussion.  In  fact,  such 
a  cyst  cannot  be  mistaken  for  anything  else  if  ordinary  care  be  exer- 
cised in  the  examination. 

Ti'eatment. — To  bring  about  adhesive  inflammation  within  the  walls 
of  the  sac  and  thus  prevent  its  refilling,  or  to  extirpate  the  whole 
cyst,  will  be  the  only  plans  of  treatment  Avhich  can  be  followed  with 
any  certainty  of  success.  Local  applications  or  simply  emptying  the 
cyst  of  its  contents  will  be  of  no  permanent  benefit. 

After  evacuating  the  fluid,  the  cyst  must  be  freely  laid  open,  a 
thorough  application  of  iodine  made  to  its  walls,  and  the  cavity 
packed  with  oakum,  which  is  to  remain  until  suppuration  is  estab- 
lished. To  insure  the  healing  up  from  the  bottom,  the  cavity  must 
be  frequently  washed  out  by  injections,  and  a  pledget  of  oakum  kept 
inserted  to.  the  bottom  of  the  wound  to  secure  thorough  drainage. 
This  plan  Avill  sometimes  succeed,  but  as  the  outer  wall  of  the  cyst  is 
very  thinly  covered  by  tissue,  this  portion  of  the  labium  may  slough, 
and  in  such  a  contingency  the  contraction  would  afterwards  be  very 
considerable. 


VAGINISMUS.  599 

When  the  cyst  is  punctured  or  extirpated,  the  parts  should  be 
first  rolled  out  as  much  as  possible,  that  the  tumor  may  become  more 
superficial.  In  this  way  we  avoid  a  large  plexus  of  vessels  which 
lies  in  the  labium,  Avhich  would  otherwise  be  directly  in  front,  and  the 
cicatrix  which  is  to  form  will  then  be  so  far  within  the  vaginal  outlet 
as  to  be  but  little  exposed  to  irritation. 

For  the  removal  of  a  cyst  of  this  nature,  the  patient  must  be  ether- 
ized, and  placed  on  the  back  with  the  limbs  flexed  on  the  abdomen. 
Then,  as  the  labium  is  everted  by  an  assistant,  the  operator  catches 
up  the  cyst  between  the  thumb  and  forefinger,  so  as  to  put  the  parts 
covering  the  cyst  on  the  stretch.  An  incision,  some  two  inches  long, 
must  be  made  parallel  to  the  course  of  the  labia,  and  with  great  care, 
down  on  to  the  cyst.  Then  by  tearing  the  tissues  Avith  the  handle  of 
a  scalpel,  and  by  snipping  them  with  a  pair  of  scissors,  and  by  the 
proper  amount  of  traction  the  attempt  must  be  made  to  remove  the 
cyst  entire.  It  is  rare  that  this  can  be  done,  for  rupture  and  the 
escape  of  the  contents  of  the  cyst  will  readily  take  place.  But  care 
and  a  steady  hand  must  be  employed  until  a  sufficient  portion  has 
been  dissected  out  to  serve  as  a  guide  for  the  removal  of  the  whole. 

Some  of  these  cysts  are  thus  removed  without  difficulty,  while 
others  extend  so  far  within  the  pelvis  that  I  have  doubted  their  con- 
nection with  the  labial  glands.  The  attachment  of  the  last  cyst  of 
this  kind  which  I  removed  extended  to  the  periosteum  on  the  inner 
face  of  the  left  ramus,  and  when  it  had  all  been  removed  a  most 
formidable  opening  was  left. 

It  is  highly  important  that  union  by  the  first  intention  should  be 
gained  as  far  as  possible.  With  this  view,  I  introduce  deep  silver 
sutures  from  above  downward,  so  as  to  bring  the  soft  parts  into  appo- 
sition, if  it  can  be  done.  When  this  is  not  practicable,  I  endeavor 
to  gain  what  I  can,  but  then  leave  always  in  the  lower  angle  of  the 
wound  a  little  oakum,  Avhich  must  extend  to  the  deepest  portion  of  the 
wound,  to  insure  the  drainage  of  any  accumulation  of  pus.  Fre- 
quently all,  or  at  least  a  large  portion,  will  then  heal  by  the  first 
intention,  and  the  sinus  Avill  close  soon  afterwards. 

Vaginismus. — This  subject  is  now  presented  without  any  special 
connection  with  the  preceding,  beyond  having  a  common  locality,  and 
because  it  cannot  well  be  classified  elsewhere. 

It  is  to  be  regarded  purely  as  a  symptom,  denoting  reflex  irritation, 
of  which  the  chief  expression  is  an  exaggerated  sensitiveness  about 
the  hymen  and  vaginal  outlet.  As  the  in-itation  is  transmitted  through 
the  sympathetic  nerves,  the  effect   is  experienced   at   its   terminal 


600      DISEASES    OF    EXTERNAL    ORGANS    OF    GENERATION. 

branches  in  the  erectile  tissue  distributed  about  the  entrance  to  the 
vagina. 

It  is  found  only  in  anaemic  and  excessiv^ely  nervous  women,  and  in 
those  who  have  in  some  manner  overtaxed  their  nervous  systems. 
Their  general  condition  renders  them  peculiarly  liable  to  neuralgia, 
of  which  the  symptom  under  consideration  is  but  a  kindred  ailment. 
The  locality  is  determined  as  if  it  were  by  accident,  or  by  some  law 
of  which  we  are  ignorant.  It  is  an  exception  to  find  any  local  ex- 
citing cause ;  occasionally  there  may  be  some  cicatricial  tissue  about 
the  perineum  or  neck  of  the  uterus,  or  some  local  inflammation  or 
disease  of  the  vagina,  vulva,  meatus,  urethi'a,  or  vesical  neck. 

Vaginismus,  which  is  the  name — although  an  inaccurate  one — given 
to  this  condition,  was  first  recognized  by  Dr.  Sims,  in  1857,  and  in 
his  Avork  on  Uterine  Surgery  it  is  described  and  treated  as  a  distinct 
local  lesion.  My  experience  does  not  coincide  with  his,  as  I  have 
never  failed  to  find  some  condition,  as  a  displacement,  a  limited  cellu- 
litis, a  fissure  in  either  the  rectum  or  neck  of  the  bladder  as  the  excit- 
ing cause.  But  even  when  apparently  due  to  a  local  inflammation, 
such  as  a  discharge  from  the  uterine  canal,  it  will  be  found  that  treat- 
ment directed  solely  to  removing  this  discharge  Avill  seldom  relieve  the 
vaginismus.  By  making  a  most  thorough  examination  we  will  rarely 
fail  to  detect  the  remains  of  a  cellulitis,  between  one  or  the  other 
broad  ligament,  which  obstruct  the  circulation  to  a  greater  or  less 
extent,  and  cause  the  discharge.  If  a  cellulitis  exists  or  a  displace- 
ment or  a  fissure,  such  condition  must  be  treated.  Frequently  all 
three  exist  together,  and  they  must  all  be  removed,  and  some  improve- 
ment made  in  the  general  condition,  both  morally  and  physically, 
before  the  vaginismus  can  be  permanently  cured. 

Dr.  Sims  recommended  the  entire  removal  of  the  hymen  with  a  pair 
of  scissors,  and  the  insertion  of  one  of  his  vaginal  glass  plugs  until 
the  parts  had  healed.  He  directed  the  plug  to  be  removed  from  time 
to  time,  and  injections  used,  as  after  the  operation  for  opening  the 
vagina.  After  the  parts  had  healed,  the  circular  cicatrix,  made  by 
the  previous  operation,  was  freely  divided  at  different  points.  He 
then  made  two  incisions,  across  the  course  of  the  muscle,  so  that  they 
came  together,  like  the  upper  portion  of  the  letter  Y,  and  were  then 
continued  through  the  perineum  as  a  single  incision,  until  the  vaginal 
outlet  had  been  fully  opened.  The  plug  was  again  used  until  the 
parts  had  healed. 

This  operation  sometimes  gives  a  remarkable  degree  of  relief  ac- 
companied by  much  improvement  in  the  nervous  symptoms,  but  I  have 


VAaiNISMUS.  601 

found  that  the  difficulty  generally  returns.  In  fact,  I  have  never  met 
with  a  permanent  cure  unless  the  exciting  cause  was  sought  out  and 
removed.  Where  the  vaginal  entrance  is  unusually  small,  and  the 
woman  has  not  learned  to  exercise  self-control,  I  am  sometimes 
obliged  to  perform  the  operation,  but  never  under  other  circum- 
stances. 

I  generally  give  ether  to  ascertain  at  the  beginning  the  cause  of 
the  difficulty.  If  due  to  a  displacement,  I  attempt  at  once  to  correct 
it ;  if  I  find  a  fissure  in  the  anus,  I  operate  without  delay  by  mode- 
rate dilatation,  bringing  the  parts  well  into  view  and  completing  the 
operation  by  drawing  a  knife  through  the  tract  of  the  ulcer.  If  I 
find  the  remains  of  cellulitis,  and  there  is  nothing  urgent,  I  simply 
put  the  vaginal  outlet  thoroughly  on  the  stretch  at  the  completion  of 
the  examination.  I  direct  hot  vaginal  injections  of  water  to  be  given 
night  and  morning  as  the  only  local  treatment.  The  bowels  are  care- 
fully regulated,  and  every  attention  given  to  improving  the  general 
condition.  Sun-baths  are  to  be  used,  more  fresh  air  obtained,  and 
some  congenial  occupation,  involving  moderate  exercise,  must  be  found 
to  engage  the  time  of  the  patient.  One  of  the  first  steps  towards  her 
cure  will  be  to  get  her  away,  temporarily  at  least,  from  the  exciting 
cause  of  irritation  to  her  nervous  system:  this  is  frequently  her 
husband. 

There  is  a  certain  condition  Avhich  is  almost  always  accompanied 
by  a  moderate  cellulitis  in  one  of  the  broad  ligaments,  rendering  the 
female  devoid  of  all  sexual  desire.  For  a  time,  woman-like,  she  will 
submit  to  marital  approaches  through  a  sense  of  duty,  but,  after  a 
while,  by  degrees,  their  suggestion  even  excites  a  feeling  of  disgust. 
If  she  continues  to  submit  to  what  she  supposes  she  is  obliged  to  do, 
this  hyperaesthesia  and  spasm  become  finally  developed  as  an  earnest 
of  the  disgust,  in  the  same  manner  as  the  gullet  closes  spontaneously 
against,  and  rejects  a  nauseous  draught.  If  the  necessary  treatment 
can  be  administered  by  degrees,  this  condition  will  disappear  without 
an  operation,  and  the  woman  will  return  to  her  duties  as  a  wife  with 
very  different  feelings. 

When  the  operation  has  to  be  done,  I  perform  it  in  a  manner  differ- 
ing somewhat  from  that  practised  by  Dr.  Sims.  The  patient  is  placed 
on  the  back  with  the  limbs  drawn  up  ;  after  etherization,  a  speculum 
is  introduced  under  the  arch  of  the  pubis,  so  as  to  bring  the  posterior 
wall  of  the  vagina  into  view.  The  index  finger  is  inserted  within  the 
anus  and  the  sphincter  is  pressed  up  against  the  posterior  wall  of  the 
vagina.    It  is  then  easy  to  divide  with  scissors  the  fibres  encircling 


.602      DISEASES    OF    EXTEKNAL    ORGANS    OF    GENERATION. 

the  vagina  on  each  side,  just  within  the  fourchette,  and  about  three- 
quarters  of  an  inch  apart.  This  does  not  allow  a  prolapse  of  the 
vaginal  wall,  as  when  the  perineum  is  lacerated,  but  does  permit 
of  an  equal  extent  of  dilatation  of  the  outlet  by  the  glass  plug. 

Vaginitis. — Inflammation  of  the  mucous  membrane  due  to  venereal 
diseases  will  not  be  treated  of,  nor  will  cancerous  growths  be  again 
considered  under  this  head,  but  only  the  eifects  of  cold  or  injury,  and 
benio-n  growths  in  the  vagina  and  uterine  canal. 

Inflammation  of  the  mucous  membrane  covering  the  cervix,  vagina, 
and  vulva,  is  a  very  common  result  of  cold  and  local  injury.  Expo- 
sure to  cold  will  cause  inflammation  in  the  cervical  mucous  follicles, 
which  may  in  time  subside,  or  leave  the  woman  liable  to  relapse.  It 
will  often  happen  that  a  circumscribed  and  unsuspected  attack  of 
cellulitis  has  been  contracted  at  the  same  exposure.  Certain  changes 
may  afterwards  take  place  in  the  circulation  of  the  cellular  tissue,  so 
that  one  condition  will  react  on  the  other,  particularly  if  the  exposure 
to  cold  or  the  over-exertion  has  been  excessive. 

Repeated  attacks  of  inflammation  of  the  lining  membrane  of  the 
vagina  and  that  covering  the  labia  may  be  excited  by  a  similar  condi- 
tion in  the  cervical  canal,  and  may  entirely  disappear,  but  the  products 
of  each  attack  of  inflammation  Avill  remain  within  the  cervix  ready  to 
set  up  a  fresh  development.  This  condition  of  the  cervix  is  commonly 
termed  chronic  inflammation,  in  regard  to  which  my  views  have  been 
fully  expressed  in  a  previous  chapter.  I  do  not  believe  that  such  a 
pathological  state  can  exist.  After  an  attack  of  inflammation,  its 
products  are  easily  recognized,  and  chiefly  there  is  manifest  such  a 
change  in  the  condition  of  the  bloodvessels  as  leads  to  increased  secre- 
tion.  The  retention  of  a  portion  of  this  secretion  within  so  confined 
a  space,  may  in  turn  react  on  the  mucous  follicles  and  thus  keep  up  a 
diseased  action  which  would  disappear  sometimes,  as  in  the  vagina, 
by  resolution,  if  the  condition  and  environment  were  diff"erent. 

The  same  may  be  true  regarding  the  lining  membrane  of  the  Fallo- 
pian tubes.  When  inflammation  has  been  once  produced  in  them  by 
cold  or  gonorrhoea,  it  never  subsides  during  the  generative  life  of  the 
ovaries,  but  leads  to  sterility  and  other  troubles.  This  condition  of  in- 
flammation has.  been  termed  salpingitis,  and  after  this  mention  I  will 
not  again  refer  to  it,  since  we  have  no  means  of  recognizing  its  exist- 
ence or  its  products  initil  after  death. 

Many  opinions  have  been  advanced  as  to  the  cause  of  inflammation 
of  the  vaginal  mucous  membrane. 


VAGINITIS — PRURITUS.  C03 

It  occurs  as  gonorrhcea,  a  subject,  however,  which  the  scope  of 
this  work  does  not  embrace.  It  doubtless  is  also  produced  by  expo- 
sure, want  of  cleanliness,  and  the  presence  of  pediculi,  and  it  is  said 
that  certain  conditions  of  the  urine,  like  in  diabetes,  will  keep  up  the 
irritation. 

But,  for  our  purpose,  the  condition  may  be  regarded  as  the  direct 
result  of  poisoning  from  some  uterine  discharge.  This  discharge  fre- 
quently does  not  become  irritating  until  it  reaches  the  vaginal  outlet 
and  is  exposed  to  the  action  of  the  air.  The  inflammation  is  then 
first  established  on  the  vulva,  from  which  it  extends  to  the  external 
oro;ans  and  within  the  vagina. 

Some  women  suffer  from  this  malady  after  any  unusual  exertion, 
after  sexual  intercourse,  and  after  each  menstrual  period,  but  it  dis- 
appears often  in  a  short  time,  without  leaving  a  trace. 

A  severe  attack  w^ill  be  ushered  in  by  a  chill  and  fever,  a  feeling 
of  great  heat  and  fulness  in  the  vagina,  back-ache,  irritation  of  the 
bladder  and  itching,  some  relief  as  to  the  more  urgent  symptoms  fol- 
lowing as  soon  as  the  discharge  bacomss  established.  The  disease 
will  then  gradually  subside,  or,  as  I  have  known  in  several  instances, 
the  vaginitis,  when  at  its  height  will  suddenly  disappear,  as  by  metas- 
tasis, on  the  advent  of  an  attack  of  cellulitis  or  peritonitis. 

But  the  cases  which  we  meet  with  most  frequently  in  practice  will 
not  be  of  so  serious  a  character.  Yet  few  diseases  to  which  women 
are  specially  subject,  are  attended  with  more  continued  suffering  and 
annoyance  than  this  one. 

The  pruritus,  or  itching,  will  often  be  intolerable,  and  is  made  worse 
as  soon  as  the  woman  becomes  warm  in  bed,  and  is  unable  to  resist 
seeking  the  momentary  relief  which  scratching  and  tearing  her  person 
will  afford.  I  know  of  nothing  which  is  so  calculated  to  induce 
insanity  as  an  attack  of  pruritus  ;  for  often  until  the  disease  has  run 
a  certain  course,  nothing  apparently  relieves  it,  except  an  anaesthetic. 

I  have  had  several  cases  under  my  care  which  gave  me  much  con- 
cern on  account  of  the  critical  condition  due  to  loss  of  sleep,  and  the 
exhaustion  from  want  of  nourishment. 

A  vaginal  examination  Avill  rarely  show  a  condition  sufficient  to 
account  for  the  suffering.  There  will  be  found  a  more  profuse  cervi- 
cal discharge  than  usual,  the  mucous  membrane  of  the  vagina  will  be 
of  a  natural  color  within  the  passage,  but  becoming  red  and  dry  as 
it  blends  with  that  covering  the  outlet,  which  will  always  be  the  more 
inflamed.     But  occasionally  the  whole  lining  membrane  of  the  pas- 


604      DISEASES    OF    EXTERNAL    ORGANS    OF    GENERATION. 

sage  and  external  organs  -will  be  inflamed.  ^The  parts  -will  be  thrown 
into  folds,  and  the  papillae  prominent,  so  as  to  have  a  deep  red 
and  roughened  appearance  of  the  mucous  membrane.  At  first  there 
will  be  an  absence  of  secretion,  and  the  parts  hot  and  swollen,  but 
at  a  later  stage  the  secretion  of  pus  may  be  profuse.  The  case  may 
be  still  further  complicated  by  the  formation  of  an  abscess  in  the 
deeper  tissues  of  the  labia.  But  between  the  two  extremes  we  will 
find  every  shade  in  the  degree  of  inflammation. 

Treatment. — A  thorough  injection  of  warm  water  must  be  first 
given,  a  speculum  introduced,  and  the  parts  dried.  If  very  much 
excoriated,  the  parts  can  be  best  dried  by  applying  a  piece  of  soft 
linen  spread  out  over  them.  Under  ordinary  circumstances  a  soft 
sponge  will  answer,  but  it  should  never  be  used  for  another  case. 
The  greatest  cleanliness  of  person  and  instruments  should  be  observed, 
for  there  is  no  question  of  the  communicability  of  this  poison  from 
one  woman  to  another  by  means  of  the  discharge.  It  can  be,  and  is 
frequently,  thus  transmitted,  through  carelessness  on  the  part  of  the 
physician  or  the  nurse. 

As  the  patient  lies  on  the  side,  with  the  vagina  fully  exposed  by  a 
speculum,  a  solution  of  nitrate  of  silver  must  be  applied  within  the 
cervical  canal,  and  over  every  portion  of  the  vaginal  mucous  mem- 
brane and  outlet.  A  solution  of  forty  grains  to  the  ounce  of  water 
is  the  strength  I  generally  use.  For  the  uterine  canal  the  applicator 
will  have  to  be  employed,  but  for  the  vagina  and  outlet  a  small  sponge 
probang  or  a  portion  of  cotton  twisted  around  the  end  of  the  swab 
stick  is  best.  It  is  the  best  plan  to  pour  out  a  small  quantity  into  a 
shallow  vessel,  into  which  the  probang  may  be  dipped  from  time  to 
time,  and  the  solution  applied  until  the  whole  surface  becomes  whitened. 
After  this  the  speculum  is  withdrawn,  the  patient  on  the  back,  and 
some  cotton  packed  into  the  sulcus,  below  the  perineum,  to  protect 
the  clothing.  Then,  as  an  assistant  exposes  the  inner  face  of  the 
vulva,  by  pressure  of  a  hand  on  each  side,  the  same  application  must 
be  thoroughly  made  to  it.  Whenever  the  inflammation  has  extended 
to  the  parts  covered  with  hair,  it  may  be  necessary  to  shave  them. 

As  soon  as  the  parts  have  dried  they  are  to  be  freely  covered  with 
zinc  ointment  .or  vaseline,  and  a  soft  piece  of  linen,  about  three  inches 
long,  and  as  wide,  must  be  laid  between  the  labia,  and  pushed  suflS- 
ciently  within  the  vagina  to  be  held  in  place.  Afterwards  the  patient 
must  be  put  to  bed.  The  application  of  nitrate  of  silver  will  cause 
but  little  pain  after  a  few  moments ;  in  fact,  if  it  should  cause  pain 
this  will  add  nothing  to  the  distress,  since  it  brings  relief  from  the 


TREATMENT    OF    VAGINITIS.  605 

itching.  Before  bedtime  an  injection  of  hot  water  must  be  adminis- 
tered, containing  a  teaspoonful  of  chloride  of  ammonium  to  each  pint. 
Either  borax,  bicarbonate  of  soda,  or  chlorate  of  potash  may  be  used 
for  the  same  purpose,  although  neither  is  so  efficacious.  After  the 
injection  the  ointment  must  be  again  freely  applied.  These  injections 
must  be  administered  two  or  three  times  a  day,  the  patient's  hips 
being  elevated  for  the  purpose.  On  the  following  morning  after  the 
injection  has  been  given,  a  mass  of  cotton  or  oakum,  thoroughly 
saturated  with  glycerine,  must  be  placed  in  the  vagina.  To  the 
glycerine  should  be  added  a  few  drops  of  impure  carbolic  acid,  and 
the  dressing  must  be  smoothly  spread  out  along  the  length  of  the 
vagina,  so  as  to  keep  the  walls  of  the  passage  from  coming  together. 
After  each  injection  a  fresh  dressing  must  be  placed  within  the  vagina. 
Should  there  be  much  heat  and  swelling  a  few  spoonfuls  of  alcohol 
can  be  added  to  the  injection,  which,  with  the  chloride  of  ammonium, 
will  hasten  the  evaporation,  and  by  this  means  lower  the  temperature. 
If  the  case  happens  to  be  a  mild  one,  the  application  of  the  impure 
carbolic  acid  w^ill  answer  perfectly  well.  Glycerine  is  invaluable  as 
a  disinfectant,  and  for  reducing  capillary  congestion  through  its  gi-eed 
for  moisture. 

The  strength  of  the  nitrate  of  silver  solution  must  be  increased 
according  to  the  severity  of  the  case,  and  at  some  special  point  it  may 
even  be  sometimes  necessary  to  resort  to  the  solid  stick.  These  appli- 
cations frequently  have  to  be  repeated  in  four  or  five  days,  if  a  decided 
relief  has  not  been  gained. 

Some  severe  forms  of  this  disease  are  relieved  by  filling  the  vagina 
and  covering  the  external  parts  with  a  thin  paste,  or  poultice,  made  of 
fuller's  earth,  over  which  a  napkin  is  to  be  placed  for  protection,  in 
the  same  manner  as  for  an  infant.  A  little  glycerine,  added  to  the 
water  with  which  the  fuller's  earth  is  mixed,  will  prevent  its  drying 
rapidly.  As  it  begins  to  get  dry  and  irritating  it  is  to  be  removed 
from  the  vagina  by  means  of  an  injection,  and  that  from  the  labia 
must  be  washed  off  with  a  jet  from  the  syringe,  and  not  wiped  away 
by  a  cloth.  I  suppose  that  a  mud  poultice,  made  from  any  earth 
Avhich  has  been  reduced  to  an  impalpable  powder,  would  answer  the 
same  purpose.  I  happened  to  use  fuller's  earth,  the  Cimolia purpu- 
rescens,  from  my  knowledge  of  it  as  an  old  woman's  remedy  for 
"taking  the  heat  out"  of  an  inflamed  breast  or  nipple. 

The  disinfecting  and  deodorizing  properties  of  common  earth,  and 
its  power,  when  damp,  of  lowering  the  temperature  of  an  inflamed 
surface,  has  long  been  known  to  the  surgeon. 


606   DISEASES  OP  THE  CERVIX  AND  UTERINE  CANAL. 

Until  the  patient  has  been  greatly  relieved  she  should  remain  in 
the  recumbent  position,  with  her  hips  somewhat  elevated. 

One  of  the  first  steps  in  the  treatment  of  this  condition  should  be  to 
effect  a  proper  action  of  the  bowels  by  a  prompt  saline  cathartic.  If 
the  bowels  have  been  sluggish  a  dose  of  calomel  and  soda  Avill  prove 
useful  in  relieving  the  portal  circulation,  so  that  the  pelvic  vessels 
may  become  less  charged  with  blood.  The  patient  should,  if  neces- 
sary, have  an  anodyne  to  overcome  excessive  pain  or  sleeplessness. 

As  a  local  application  a  small  quantity  of  chloroform  may  be  rubbed 
into  an  emulsion,  or  mixed  with  simple  cold  cream  spread  upon  a 
cloth,  and  applied  between  the  labia.  As  an  anodyne  Dover's  powder 
is  preferable,  when  it  can  be  retained,  and  to  it,  at  night,  three  to 
five  grains  of  quinine  may  be  added. 

Should  an  abscess  result  from  this  Inflammation,  it  should  be  poul- 
ticed, and  opened  as  soon  as  fluctuation  can  be  detected,  in  order  to 
prevent  the  burrowing  of  the  pus.  The  point  of  puncture  should  be 
made  Avell  within  the  vaginal  outlet,  for  the  reasons  given  when  de- 
scribing the  operation  for  removing  labial  cysts.  It  will  be  necessary 
also  to  give  some  attention  to  the  general  condition,  not  only  because 
the  patient's  strength  is  always  impaired,  but  because  any  improvement 
in  it  will  hasten  the  healing  of  the  abscess. 

Certain  Conditions  of  the  3Iucous  3Iemhrcine  covering  the  Cervix 
and  of  the  Membrane  lining  the  Uterine  Canal. — The  structure  proper 
of  the  cervix  is  dense,  and  contains  but  few  bloodvessels  or  nerves  in 
comparison  with  the  other  portions  of  the  uterus.  But  its  surface  is 
covered  with  erectile  tissue  continued  from  the  vaginal  walls,  and  this 
is  freely  supplied  with  bloodvessels  and  with  nerve  fibres  from  the  sym- 
pathetic system.  It  is  through  the  medium  of  these  nerves,  that 
morbid  processes  in  the  cervix,  by  reflex  action,  may  cause  a  serious 
impairment  of  health,  and  even  establish  diseases  in  remote  parts  of 
the  body.  It  has  been  already  stated  that  the  sympathetic  presides 
over  nutrition  through  life,  and  over  the  organs  of  generation  during 
the  period  of  their  activity. 

As  a  consequence  of  this  close  relation,  it  is  evident  that  the 
general  nutrition  must  soon  suff'er  if  a  condition  long  exists  in  the 
generative  organs  from  which  morbid  reflex  irritations  can  emanate. 
The  presence  of  cicatricial  and  dense  tissue  in  the  cervix  will  sooner 
or  later  excite  this.  If  the  mucous  follicles  become  inflamed,  undergo 
cystic  degeneration,  and  are  at  length  destroyed,  phthisis  so  often  re- 
sults, that  the  relation  of  cause  and  effect  cannot  be  doubted.  When 
the  character  of  the  raucous  membrane  covering  the  cervix  has  been 


NEURALGIA    FROM    DISEASE    OF    THE    CERVIX.  607 

destroyed,  either  by  inflammation  or  by  the  continued  application  of 
some  remedy  to  heal  an  erosion,  the  deeper  tissues  become  dense  and 
undergo  atrophy. 

To  the  destruction  or  change  in  character  of  the  mucous  membrane 
covering  the  cervix  is  due  much  of  the  angemia  and  neuralgia  of 
■women. 

I  do  not  claim  that  the  general  health  of  every  woman  who  has  a 
scar  on  the  cervix  will  suffer,  or  that  she  will  always  have  neuralgia 
in  consequence.  But  it  has  been  demonstrated  to  my  mind  as  clearly 
as  anything  we  accept  as  truth  in  medicine,  that  there  exist  a  rela- 
tion of  cause  and  eflfect  under  the  following  circumstances.  If  a 
woman  receives  an  injury  in  labor,  as  a  laceration  of  the  cervix,  and 
is  in  such  perfect  health  as  to  be  able  to  withstand  the  irritation,  she 
may  go  for  an  indefinite  time  without  suff"ering  any  evil  consequences. 
But  if  she  should  ever  become  anaemic,  and  the  victim  of  neuralgia, 
with  this  condition  of  the  cervix,  she  will  not  recover  her  health  until 
the  source  of  irritation  has  been  removed  by  the  surgeon,  or  by  nature 
after  she  has  gone  through  a  change  of  life. 

Twenty-five  years  ago  or  more,  it  Avas  the  practice  to  apply  nitrate 
of  silver  to  the  cervix  for  almost  every  condition,  real  or  imaginary. 
It  was  then  rare  to  find  a  woman  who  had  been  so  treated,  whose 
cervix  uteri  was  not  hardened  to  an  extreme  degree. 

These  women  were  as  a  rule  martyrs  to  neuralgia,  and  were  as 
commonly  anaemic.  Many  became  addicted  to  the  use  of  opium,  and 
not  one  obtained  relief  unless  the  cervix  was  amputated,  or  they  lived 
until  a  change  was  brought  about  after  the  menopause.  Let  me 
remind  the  reader  than  I  am  not  advocating  amputation  of  the  cervix, 
by  which  the  surface  would  be  left  to  heal  by  cicatrization.  There 
are  special  objections  to  the  presence  of  cicatricial  tissue,  which  have 
been  already  treated  of,  but  not  in  this  connection.  Here  the  diffi- 
culty lies  not  so  much  in  the  character  of  the  tissue  as  in  the  fact  that 
the  fibres  of  the  sympathetic  become  involved  in  the  contraction. 

But  to  return  to  our  subject:  Now  that  a  certain  time  has  elapsed 
since  this  practice  has  gone  into  disuse,  it  is  as  rare  to  find  a  woman 
suffering  to  the  same  extent  as  it  formerly  was  to  meet  with  one  who 
had  no  suffering.  Anaemia  is  no  less  common,  for  we  have  not  yet 
removed  all  the  causes  which  impair  the  nutritive  glands.  But  my 
case-books  demonstrate  the  fact  that  for  every  woman  which  I  am 
now  called  upon  to  treat  for  neuralgia  I  had  five  under  ray  care 
fifteen  or  sixteen  years  ago,  when  I  began  to  study  this  condition. 

So  much  has  already  been  advanced  on  this  subject  in  different 


608   DISEASES  OF  THE  CERVIX  AND  UTERINE  CANAL. 

parts  of  this  work,  that  it  cannot  be  dwelt  upon  at  much  greater 
length  without  repetition.  The  various  lesions  of  the  cervix  which 
result  from  childbirth,  and  become  reflex  sources  of  disease,  have  also 
been  fully  treated  of  elsewhere,  and  my  chief  purpose  in  referring 
ao"ain  to  these  morbid  conditions  is  in  reference  to  certain  affections 
of  the  mucous  follicles  within  the  canal. 

The  exaggerated  action  of  these  glands,  and  the  frequent  recur- 
rence of  inflammation  in  them,  are  so  often  dependent  on  a  diseased 
condition  of  the  connective  tissue  of  the  pelvis,  that  it  is  to  be  sus- 
pected in  every  case.  Sufficient  has  also  been  stated  regarding  the 
treatment  of  erosions  which  follow  upon  this  increase  of  secretion,  and 
no  further  allusion  to  them  need  be  made  here. 

Single  Nabothian  follicles  sometimes  become  inflamed  and  reach  a 
large  size,  so  that  they  can  be  easily  felt  with  a  probe  projecting  at 
some  distance  into  the  canal.  These  growths  always  excite  a  great 
deal  of  local  irritation,  and  cause  an  increase  of  secretion.  The 
most  effective  method  of  removing  them  is  to  clip  them  off"  with  a 
pair  of  scissors,  after  first  catching  up  the  mass  with  a  tenaculum, 
which  may  also  serve  as  a  guide.  If  necessary  to  facilitate  their 
removal,  the  canal  should  be  dilated,  and  afterwards  a  free  applica- 
tion of  iodine  should  be  made  to  the  denuded  surface. 

Whenever  the  follicles  undergo  cystic  degeneration,  they  should  be 
punctured  so  as  to  relieve  the  pressure  they  exert  on  others  in  their 
neighborhood.  The  formation  of  these  cysts  frequently  excites  a 
great  deal  of  nervous  disturbance,  and  fully  illustrates  the  effects  of 
pressure  on  the  sympathetic  fibres.  It  is  seldom  that  I  have  not  had 
some  patient  under  my  care  suffering  from  this  cause,  and  they  often 
return  to  me  at  long  intervals,  recognizing  from  their  feelings  the 
necessity  for  having  the  cysts  punctured.  I  have  a  lady  under  my 
care  at  present  who  is  so  sensitive  that  as  soon  as  a  single  cyst  de- 
velops she  immediately  returns  for  relief.  I  have  seen  her  about 
once  in  six  months  during  the  past  five  years,  and  she  has  not  been 
mistaken  vipon  any  occasion  as  to  the  cause  of  her  pain. 

When  within  the  canal  they  cannot  be  so  readily  reached,  and 
when  detected,  from  the  rough  surface  presented  by  them,  they  are 
best  ruptured  by  means  of  Thomas's  dull  wire  curette  drawn  over 
their  surface  with  some  degree  of  pressure. 

These  follicular  growths  sometimes  umlergo  development  into  the 
ordinary  mucous  polypus,  from  which  the  loss  of  blood  is  generally 
excessive.  They  are  occasionally  found  in  young  women,  but,  as  a 
rule,  they  are  developed  in  middle  life,  or  as  the  woman  approaches 


DISEASES    OF    THE    CERVICAL    CANAL.  609 

the  menopause.  After  a  change  of  life  has  taken  place,  and  the 
cervix  has  disappeared,  these  growths  are  found  hanging  free  in  the 
vagina.  So  long  as  they  remain  within  the  uterine  canal  they  are  a 
source  of  irritation  which  leads  to  hemorrhages  ;  but  when  they  hang 
free  in  the  vagina,  the  tendency  to  a  loss  of  blood  ceases,  and  they 
no  longer  cause  any  irritation.  There  is  a  stage,  however,  in  the 
growth  when  the  polypus  protrudes  just  enough  to  close  the  os  and 
cause  a  retention  of  the  secretions  within  the  uterus.  When  this  dis- 
charge, already  partially  decomposed,  escapes  by  degrees  into  the 
vagina,  its  presence  often  causes  itching,  and  sometimes  keeps  up  a 
vaginitis.  This  form  of  polypus  will,  as  a  rule,  be  found  presenting 
at  the  03  if  the  examination  be  made  just  at  the  close  of  menstruation. 
If  there  is  bleeding  from  the  uterus,  and  no  particular  cause  can  be 
detected,  it  is  always  the  proper  treatment,  as  a  first  step,  to  dilate 
the  canal. 

When  brought  into  view  this  growth  is,  in  appearance,  not  unlike  a 
mass  of  tenacious  mucus  saturated  with  blood,  and  it  bleeds  on  the 
slightest  touch.  If  seized  by  a  pair  of  smooth  forceps,  and  drawn 
out,  its  pedicle  can  be  traced  with  a  probe  to  some  distance  within 
the  canal.  The  natural  impulse  is  to  tear  the  growth  away ;  this 
can  be  readily  done,  but  if  force  be  used  an  attack  of  cellulitis  will 
be  more  likely  to  result  than  after  the  removal  of  a  large  pedunculated 
polypus. 

There  certainly  exists  a  closer  relation  between  the  mucous  mem- 
brane of  the  vagina,  the  uterine  canal,  and  the  peritoneum  and  con- 
nective tissue  of  the  pelvis,  than  is  generally  supposed.  I  have  had 
this  accident  several  times  occur  from  twisting  oft"  such  a  growth.  I 
now  always  divide  the  pedicle  close  to  its  attachment  with  a  pair  of 
scissors  as  the  mass  is  held  on  the  stretch  by  forceps.  After  its 
removal  an  application  of  iodine  should  be  made,  but  not  until  the 
canal  has  been  syringed  out  with  tepid  water  should  a  sponge  tent  be 
used.  Although  there  may  be  no  bleeding,  it  is  always  a  prudent 
precaution  to  use  a  moderate  tampon,  and  to  keep  the  woman  quiet 
in  the  recumbent  position  for  a  few  hours  after  the  operation. 

Disease  of  the  Lining  Membrane  of  the  Uterus. — We  will  now 
consider  a  condition  of  the  lining  membrane  of  the  uterus  which  is 
exceedingly  common,  and  but  little  understood.  With  women  who 
have  had  a  number  of  children,  or  who  have  miscarried  frequently, 
certain  changes  take  place  which  render  them  liable,  not  only  to 
excessive  menstruation,  but  sometimes  to  loss  of  blood  in  the  interval. 
The  uterus  is  always  larger  than  natural,  but  not  sufficiently  so  to 
39 


610       DISEASES    OF    THE    CEEVIX    AND    UTERINE    CANAL.  • 

indicate  the  presence  of  a  fibroid  or  of  any  internal  growth.  The 
patient  will  date  her  disease  from  the  birth  of  a  child,  or  from  a 
miscarriage,  in  which  case  the  difficulty  may  be  frequently  traced  to 
a  small  portion  of  placenta  which  has  become  so  organized  as  to 
resemble  an  outgrowth  from  the  uterine  surface. 

Microscopists  have  not  yet,  to  my  knowledge,  fuUy  investigated 
this  subject,  and  I  cannot  speak  with  authority,  but  it  is  evident  that 
there  are  several  distinct  conditions  capable  of  giving  rise  to  the 
same  symptom.  Practically,  this  fact  is  of  little  importance,  since 
whatever  the  condition,  or  if  two  or  more  coexist,  the  treatment  will 
be  exactly  the  same. 

We  must  bear  in  mind  that  the  uterus  has  a  mucous  membrane 
only  as  far  as  the  internal  os,  beyond  which  the  lining  membrane  is 
an  outgrowth,  as  it  were,  from  the  muscular  tissue.  It  is,  therefore, 
free  from  mucous  follicles,  and  consequently  it  can  be  determined  by 
the  microscope  whether  the  disease  is  located  above  or  below  the 
internal  os. 

A  condition  is  frequently  met  which  some  writer  has  compared  to 
the  granulations  of  conjunctivitis.  Again,  large  flabby  granulations, 
or  fungosities,  may  exist  at  several  points  in  a  mass  together,  which 
bleed  on  the  slightest  touch.  The  favorite  site  for  these  is  in  one  or 
both  cornua  of  the  uterus,  from  which  cause  their  presence  is  fre- 
quently overlooked. 

A  common  form  of  outgrowth,  found  in  the  upper  portion  of  the 
canal,  resembles  closely  the  long  pile  of  velvet  cloth,  and  when  floated 
in  water  it  seems  to  consist  of  prolongations  of  bloodvessels  from  the 
muscular  tissue. 

I  have  also  noticed  a  thickened  condition  of  the  lining  membrane, 
which  could  be  easily  detached  in  long  strips,  like  the  skin  which  has 
been  scalded,  and  it  is  blanched  in  appearance.  It  seems  as  if  it 
Avere  soaked  in  water,  or  as  if  macerated  from  the  constant  flow  of 
serum  which  generally  accompanies  the  condition  when  there  is  no 
hemorrhage. 

But  one  mode  of  treatment  exists,  viz.,  to  remove  the  growths 
entirely,  leaving  a  healthy  surface  exposed.  The  important  point  is 
the  proper  mode  of  doing  so  with  the  least  risk  to  the  patient. 
Recamier'  devised  the  curette  for  the  removal  of  these  growths,  an 
instrument  which  has  proved  a  most  objectionable  one.  The  same 
instrument  has  been  modified  by  Simpson,  Simon,  and  Sims,  without 
removing  ths  objectionable  features.     As  regards  the  instrument  of 


GRANULATIONS    OF    THE    CERVICAL    CANAL.  611 

Dr.  Sims,  I  honestly  believe  that  the  ingenuity  of  man  has  never 
devised  one  capable  of  doing  more  injury  and  as  little  good. 

Women  suflfering  from  these  growths  are  all  exceedingly  anaemic 
from  the  long  loss  of  blood  during  menstruation,  and  from  the  leakage 
of  serum  which  has  continued  in  the  interval.  A  woman  with  anoemia 
is  always  very  susceptible  to  blood-poisoning  after  an  operation  for 
this  condition,  and  peritonitis  is  likewise  not  an  infrequent  sequel. 
I  have  known  peritonitis,  cellulitis,  pelvic  abscess,  and  even  death,  to 
occur  on  removing  these  growths  from  the  uterine  canal  with  a  curette, 
and  in  every  instance  the  operator  was  dexterous  in  the  use  of  the 
instrument.  My  vieAVS  are  based  on  a  dearly  bought  experience,  and 
I  believe  that  no  man  has  a  right  to  place  the  life  of  his  patient  in 
jeopardy  by  the  use  of  either  of  these  instruments  in  the  treatment  of 
this  condition.  Their  use  should  be  limited  to  the  removal  of  malig- 
nant disease,  under  certain  cii'cumstances,  and  then  only  with  the 
greatest  care,  for  the  walls  of  the  uterus  have  been  perforated  by 
them. 

These  growths  are  difficult  to  find,  and  it  is  rare  that  they  can  be 
detected  by  use  of  the  sound  or  probe,  and  if  the  canal  be  dilated 
to  any  extent  by  means  of  a  sponge  tent,  they  become  so  compressed 
that  the  finger  cannot  appreciate  their  presence,  and  consequently  the 
physician  is  frequently  misled.  The  use  of  the  curette  is  certainly 
a  great  aid  for  establishing  a  diagnosis,  but  unfortunately  it  removes 
both  healthy  and  unhealthy  tissue.  The  copper  wire  loop  devised  by 
Dr.  T.  G.  Thomas  is  a  safe,  and,  as  a  rule,  an  efficient  means  for  the 
removal  of  these  growths.  It  is  an  excellent  instrument  for  use  in 
the  condition  where  the  membrane  is  thickened,  and  there  is  nothing 
to  be  brought  away.  By  drawing  the  loop  with  some  pressure  over 
this  surface,  so  great  a  modifying  effect  is  established  in  the  nutrition 
of  the  parts  that  it  seldoms  fails  to  arrest  the  tendency  to  bleeding. 
It  is  also  as  effective  in  breaking  up  the  soft  villous  growths,  but  not 
so  good  for  granulations  of  a  firm  consistency.  For  more  particu- 
lar information  as  to  the  use  of  the  dull  wire  curette,  and  its  applica- 
bility in  the  diseases  of  the  uterine  canal,  the  reader  is  referred  to 
Dr.  P.  F.  Mund^'s  admirable  papers  in  the  Edinburgh  Medical 
Journal  for  March  and  April,  1878. 

I  have  for  many  years  realized  the  danger  attending  the  use  of 
Sims's  curette,  and  have  devised  another  instrument  which  has  proved 
efficacious,  and  its  use  is  singularly  free  from  bad  consequences.  ] 
began  with  a  pair  of  forceps  made  for  other  purposes,  and  modified 
them  into  the  present  shape,  which  has  remained  unchanged  for  the 


612   DISEASES  OF  THE  CERVIX  AND  UTERINE  CANAL. 

past  ten  years.  I  had  the  blades  constructed  in  shape  like  two  of 
Simpson's  scoops  coming  together  so  that  a  cross  section  of  the  two, 
when  closed,  would  be  not  unlike  the  figure  8  (see  Fig.  105).  The 
great  advantage  of  the  instrument  is  that  it  can  remove  onlj  what 
projects  above  the  common  level.  This  it  crushes  ofi"  sufficiently  close 
without  dragging  upon  or  injuring  the  surrounding  tissues. 

Fig.  105. 


Emmet's  curette  forceps. 


The  proper  mode  of  operating  is  to  place  the  patient  on  the  left 
side,  and  the  speculum  is  used.  There  is  so  little  pain  attending  the 
procedure  that  scarcely  a  necessity  exists  for  an  ansesthetic,  but  my 
rule  is  to  administer  one,  for  it  has  given  me  better  results,  and  I 
believe  that  it  does  much  towards  protecting  the  patient.  It  also 
gives  the  operator  greater  facility  by  relaxing  the  parts,  and  affords 
him  more  time  for  the  thorough  removal  of  the  growths  than  he  would 
have  if  he  were  anxious  to  terminate  the  operation  on  account  of  the 
emotions  of  the  patient. 

As  a  rule,  in  these  cases  the  canal  is  sufficiently  open  to  admit  of 
the  passage  of  the  curette  forceps,  but  if  further  dilatation  be  required, 
the  judicious  use  of  the  forceps  themselves  Avill  frequently  accom- 
plish it.  When  a  sponge  tent  is  used,  it  should  not  be  a  large  one 
nor  long  enough  to  reach  to  the  fundus.  It  is  only  necessary  to 
dilate  as  far  as  the  internal  os,  and  too  long  a  tent  should  not  be 
used.  Sometimes  a  large  tent  is  a  most  efficient  means  for  destroy- 
ing these  growths,  as  shown  by  the  history  of  a  case  detailed  in  one 
of  the  early  chapters  of  this  work,  but  since  the  pressure  must  be 
kept  up  for  several  days,  it  is  attended  with  considerable  risk  of  blood 
poisoning. 

Before  introducing  the  forceps  the  uterus  must  be  gently  drawn 
down  near  the  outlet,  by  means  of  a  tenaculum  caught  in  the  anterior 
lip.  When  brought  within  range,  so  that  the  fundus  presents  in  the 
direction  of  the  promontory  of  the  sacrum,  it  will  be  easy  to  intro- 


USE    OP    TUE    CURETTE    FORCEPS.  613 

duce  the  forceps  Avithout  employing  much  force.  They  are  to  be 
dipped  in  warm  water,  and  slightly  smeared  Avith  glycerine,  before 
being  passed  up  into  one  or  the  other  cornu.  When  the  extremity  of 
the  instrument  has  reached  the  desired  point,  its  jaws  are  to  be  gently 
separated,  then  closed  firmly  together,  and  withdrawn.  By  shaking 
the  end  of  the  instrument  in  a  basin  of  water,  anything  which  has 
been  brought  away  Avill  be  easily  dislodged.  The  operator  can  thus 
systematically  pass  over  the  whole  surface,  and  without  exerting  the 
slightest  violence.  When  satisfied  that  there  remains  nothing  more 
to  be  removed,  the  canal  must  be  gently  washed  out  by  means  of  a 
long-nozzled  hard-rubber  syringe.  This  will  be  the  most  efiicient 
means  for  guarding  against  the  occurrence  of  blood-poisoning  by  re- 
moval of  all  the  debris.  Then  a  free  application  of  iodine  to  the 
fundus  must  be  made  to  excite  contraction  of  the  uterus,  by  which 
the  quantity  of  blood  circulating  in  the  organ  will  be  diminished.  A 
small  tampon  of  cotton,  saturated  with  glycerine,  should  be  intro- 
duced, and  then,  under  all  circumstances,  the  patient  must  be  kept  in 
bed  for  several  days,  as  a  matter  of  ordinary  caution.  Vaginal  in- 
jections of  warm  water  must  be  administered  freely,  night  and  morn- 
ing, for  a  week,  even  if  there  should  be  no  discharge. 

In  anticipation  of  the  next  menstrual  period,  the  patient  is  to  be 
kept  in  bed  for  the  twenty-four  hours  before  it  makes  its  appearance, 
and  the  horizontal  position  is  to  be  maintained  while  it  continues. 
Should  the  flow  still  continue  too  free,  the  operation  is  to  be  repeated 
several  days  after  it  has  ceased,  and  there  is  a  certainty  almost  of 
finding  some  growth  which  was  overlooked  at  the  previous  operation. 
After  having  removed  the  source  of  irritation  the  general  health  will 
rapidly  improve,  and  under  the  occasional  use  of  iodine  within  the 
uterine  canal  the  uterus  will  gradually  return  to  its  normal  size. 


614  VESICO-    AND    RECTO-VAGINAL    FISTULA, 


CHAPTER    XXXI. 

VESICO-  AND  RECTO-VAGINAL  FISTULA. 

History  and  development  of  the  operation — Silver  sutures — Button  suture — ^^Pre- 
paratory treatment — Mode  of  operating. 

A  VESICO- VAGINAL  or  a  recto-vaginal  fistula  may  be  defined  to  be  an 
abnormal  opening,  the  result  of  an  accident,  between  the  bladder  and 
vagina,  or  between  the  rectum  and  vagina,  through  which  the  contents 
of  either  may  escape. 

It  would  scarcely  be  in  keeping  with  the  practical  character  of  this 
work  to  give  the  history  of  the  early  efforts  made  to  close  these 
openings.  Although  over  two  hundred  years  ago,  in  Holland,  a 
vesico-vaginal  fistula  was  brought  into  view  by  means  of  a  speculum, 
and  sutures  were  applied  to  it,  little  progress  was  made  in  any  method 
of  cure.  In  France,  even  up  to  the  close  of  the  first  quarter  of  the 
present  century,  the  problem  remained  unsolved,  notwithstanding  it 
had  engaged  the  attention  of  the  great  surgical  minds  of  the  day. 

To  J.  Marion  Sims  the  world  is  indebted  for  suggesting  and  per- 
fecting the  measures  by  which  this  formerly  almost  intractable  condi- 
tion is  rendered  one  of  the  most  certain  of  relief  within  the  field  of 
surgery.  It  is  true  that  in  every  particular  feature  of  the  operation, 
on  which  his  success  depended.  Dr.  Sims  had  been  anticipated.  In 
our  own  country,  Dr.  H.  S.  Levert,^  of  Mobile,  Alabama,  had  pub- 
lished (American  Journal  of  the  Medical  Sciences,  May,  1829)  his 
experiments  in  the  use  of  silver  wire.  Mr.  M.  Gosset,  in  a  letter  to 
the  London  Lancet,  Nov.  21,  1834,  gave  an  account  of  his  method 
and  success  in  closing  a  vesico-vaginal  fistula  which  had  been  pro- 
duced by  the  cutting  through  of  a  stone  in  the  bladder.  He  used 
interrupted  sutures  of  gilded  silver  wire,  which  were  twisted,  and  as 
clearly  defines  the  advantages  of  the  metallic  sutures  as  if  given  in 
the  words  of  Dr.  Sims  himself.  The  method  of  Metzler  was  published 
in  Germany  in  1846,  and  in  the  article  not  only  is  Sims's  speculum 

•  On  Kolpokleisis,  etc.,  by  Nathan  Bozcman,  M.D.,  Richmond   and  liOuisvillo 
Medical  Journal,  October,  1867. 


DEVELOPMENT    OF    THE    OPERATION.  G15 

essentially  described,  but  also  the  use  of  clamp  sutures,  and  the  mode 
of  denuding  the  edges  of  the  fistula  with  scissors,  the  patient  being 
in  the  knee  and  chest  position. 

This  illustrates  what  I  have  often  maintained,  that  ideas  and  general 
principles  may  be  new,  but  that  mechanical  procedures  seldom  are. 
When  there  is  a  demand  for  any  invention  or  device,  it  seldom  fails 
to  be  evolved,  but  it  may  pass  out  of  use,  and  even  out  of  memory, 
only,  however,  to  be  recalled,  or  perhaps  re-originated,  when  renewed 
occasion  demands  it. 

In  this  country  Hayward,  of  Boston,  had  been  successful,  between 
1836  and  1840,  with  the  silk  suture,  while  Dr.  Mettauer,  of  Virginia, 
in  1847,  had  used  the  lead  suture,  and  in  the  account  of  his  operation 
expresses  his  conviction  that  every  case  of  vesico-vaginal  fistula  could 
be  cured.  Yet,  withal,  were  we  assured  of  the  fact  that  Dr.  Sims 
Avas  as  familiar  as  we  are  at  the  present  time  with  what  had  been 
accomplished  before  his  day,  it  should  not  lessen  the  credit  due  him. 
What  had  been  done  fell  on  barren  soil,  bore  no  fruit,  was  not  appre- 
ciated, and  was  destined  to  be  forgotten.  From  Dr.  Sims's  hand  the 
operation  was  accepted  by  the  profession ;  it  was  immediately  put 
into  successful  practice,  and  to  the  present  day  it  has  not  been 
materially  modified  for  the  better,  in  either  its  principles  or  in  its 
mode  of  execution. 

His  first  article  on  this  subject  Avas  published  in  the  Am.  Journ.  of 
Med.  Sciences,  in  1852,  and  this,  with  his  address  before  the  N.  Y. 
Academy  of  Medicine  in  1857,  on  "Silver  Sutures  in  Surgery,"  may 
be  regarded  as  a  summary  of  his  experience,  for  since  the  latter  date, 
he  has  given  nothing  to  the  profession  on  the  subject. 

Within  the  period  between  the  two  papers,  he  materially  modified 
the  mode  of  securing  the  edges  of  the  fistula.  At  first  he  employed 
the  clamp  suture,  Avhich  was  but  the  quill  suture,  through  which 
the  wire  passed,  each  end  being  held  by  a  perforated  shot  which 
Avas  compressed  at  the  proper  point  for  the  purpose  of  securing  it. 
Finally  he  adopted  the  simple  interrupted  metallic  suture  secured  by 
twisting,  as  Mettauer  and  Gosset  had  done  before  him. 

My  association  Avith  Dr.  Sims  began  at  so  short  a  period  previous 
to  his  adopting  the  interrupted  suture,  that  I  am  unable  to  judge  from 
my  OAvn  knowledge  as  to  the  merits  of  the  controversy  between  him 
and  Dr.  Bozeman  in  regard  to  their  respective  claims  for  priority.  I 
can  only  testify  as  to  the  value  of  the  method  as  taught  by  Dr.  Sims, 
my  judgment  being  based  on  an  experience  now  greater  than  his  OAvn, 
and  probably  unsurpassed  by  that  of  any  other  operator. 


616  VESrCO-    AND    EECTO-VAGINAL    FISTULA. 

One  of  the  most  important  features  in  Dr.  Sims' s  practice  was  the 
careful  preparation  of  every  case  previous  to  the  operation,  and  this 
was  the  custom  when  I  first  became  connected  with  the  Woman's 
Hospital,  in  1855. 

It  is  claimed  by  Dr.  Bozeman  that  this  practice  was  original  with 
him,  and  that  he  first  pointed  out  its  necessity.  Dr.  Bozeman  has 
maintained,  by  various  articles  in  the  medical  journals,  that  he  de- 
vised the  button  suture,  in  May  1855,  and  instituted  the  practice  of 
freely  dividing  cicatricial  bands,  and  of  dilating  the  vagina  for  the 
purpose  of  freeing  the  tissues  before  attempting  to  close  the  fistula. 

In  certain  cases,  when  the  cervix  had  been  lacerated  for  some  dis- 
tance up  the  canal  and  above  the  fistula.  Dr.  Bozeman  seems  to  have 
been  the  first  to  repair  this  injury.  This  was  done  that  the  fistula 
might  be  closed,  so  as  to  leave  the  uterus  in  a  natural  condition  in 
the  vagina,  instead  of  turning  the  cervix  into  the  bladder  as  is  some- 
times done.  I  have  always  followed  the  same  plan  when  it  could  be 
employed,  as  the  proper  one,  and  had  done  so  without  any  knowl- 
edge of  Dr.  Bozeman's  claims  of  priority,  which  are  certainly  just. 

Since  1855,  Dr.  Bozeman  has  continued  to  use  what  he  terms  the 
"  button  suture."  This  is  a  perforated  disk  of  metal  made  slightly 
concave,  and  fitted  accurately  to  the  vaginal  surface  about  the  edges 
of  the  fistula.  Through  one  of  the  holes  in  the  row  down  the  centre, 
the  two  ends  of  the  suture  are  passed  together,  and  over  these  a  per- 
forated shot  which  is  then  compressed  at  the  point  needed  to  secure 
the  sutures.  Dr.  Bozeman  has  long  since  reached  a  deo;ree  of  dex- 
terity  and  skill  in  this  operation,  by  which  nearly  every  case  coming 
under  his  care  is  cured,  if  the  condition  of  the  tissues  will  admit  of 
this  being  done  without  sacrificing  the  generative  function.  This 
result  I  believe  to  be  due  more  to  his  skill  than  to  the  special  method 
of  securing  the  edges  of  the  fistula,  for  the  results  are  equally  as  good 
with  the  simple  interrupted  suture.  In  fact,  I  believe  for  the  general 
practitioner  the  interrupted  suture  is  to  be  preferred  to  the  button 
suture,  for  this  certainly  requires  more  practice  for  its  successful  ap- 
plication. When  Dr;  Bozeman  establishes  his  claims  to  having  been 
the  first  to  employ  the  system  of  preparatory  treatment  now  in  general 
use,  it  will  entitle  him  to  far  more  credit  than  is  to  be  gained  from 
the  invention  of  any  special  suture.  When  a  case  has  been  properly 
prepared  for  an  operation,  the  edges  of  the  fistula  being  freed  from 
tension  and  well  denuded,  it  will  matter  little  whether  metallic  suture 
or  silk  be  used,  the  interrupted  suture  or  "  the  button."     A  piece  of 


ANALYSIS    OF    METHODS.  617 

sticking-plaster,  if  it  would  hold,  would  answer  every  purpose,  for 
without  regard  to  the  sutures,  all  methods  fail,  as  a  rule,  if  the  first 
steps  are  not  properly  appreciated  by  the  operator. 

Into  the  merits  of  the  controversy  between  the  late  Dr.  Simon,  of 
Heidelberg,  and  Dr.  Bozeraan  I  cannot  enter,  but  certain  features  in 
the  practice  of  Prof.  Simon,  as  given  by  himself,  are  of  too  much 
general  interest  to  be  passed  over.  If  the  success  claimed  by  Dr. 
Simon  be  up  to  the  standard  of  what  is  generally  considered  as  suc- 
cess in  this  country,  our  experience  will  amount  to  little,  for  what  we 
have  considered  as  most  essential  will  be  shown  by  his  methods  and 
results  to  be  of  no  importance.  He  did  not  admit  the  necessity  for 
any  special  preparatory  treatment ;  he  used  silk  instead  of  metallic 
sutures ;  he  allowed  his  patients  to  get  up  and  walk  about ;  and  dis- 
carded the  use  of  the  catheter,  allowing  the  patient  to  evacuate  the 
bladder  at  will.  He  alwaj^s  operated  with  the  patient  on  the  back, 
with  the  legs  flexed  on  the  abdomen,  while,  from  the  number  of  appli- 
ances he  found  necessary  to  bring  the  parts  into  view,  it  is  very  evi- 
dent that  he  only  partially  appreciated  the  efficacy  and  simplicity  of 
Sims's  speculum.  One  of  two  alternatives  impresses  me  as  the  expla- 
nation of  these  peculiar  features.  Either  the  destruction  of  tissue  is 
not  so  great  in  Germany  as  it  is  in  a  large  proportion  of  the  cases 
received  in  the  Woman's  Hospital,  or  Prof.  Simon  did  not  succeed  as 
a  rule  in  closinor  the  edges  of  the  fistula.  I  make  this  assertion 
because  I  have  demonstrated  to  my  entire  satisfaction  that  his  plan  of 
treatment  cannot  be  successfully  employed,  except  in  those  cases  in 
which  the  fistula  is  very  small,  and  in  which  there  is  a  redundancy  of 
surrounding  tissue.  Nor  is  it  possible,  under  the  most  favorable 
circumstances,  to  cure  so  large  a  proportion  of  cases  as  he  claims  by 
a  single  operation.  The  explanation,  in  all  probability,  rests  in  the 
assertion  made  by  Dr.  Bozeman,  in  the  paper  previously  referred  to, 
that  in  a  large  proportion  of  Prof.  Simon's  cases  the  fistula  was  not 
closed,  but  that  retention  of  urine  was  secured  by  the  operation  of 
kolpokleisis,  as  it  is  termed.  This  operation  consists  in  shutting  up 
the  vagina  in  part  or  entirely,  and  is  a  practice  which  is  not  indicative 
of  advance  in  this  branch  of  surgery  if  commonly  employed,  nor  is  it 
one  which  is  likely  to  be  of  permanent  benefit  to  the  patient.  But 
this  subject  will  be  again  referred  to  when  considering  the  difi'erent 
forms  of  fistula  and  the  methods  for  closing  them. 

Treatment  Preparatory  to  the  Operation  for  Vesico-vaginal  Fis- 
tula.— Unless  the  greatest  care  be  given  to  cleanliness,  a  woman  will 


618  VESICO-    AND    RECTO-VAGINAL    FISTULA. 

become  a  great  suiferer  and  a  most  loathsome  object  in  a  few  weeks 
after  receiving  this  injury.  The  external  organs  of  generation  become 
excoriated  and  oedematous  from  the  irritation  of  the  urine,  and  the 
same  condition  extends  over  the  buttocks  and  down  the  thighs.  The 
labia  are  frequently  the  seat  of  deep  ulcerations  and  occasionally  of 
abscesses.  The  mucous  membrane  of  the  vagina  is  in  part  lost,  and 
the  abraded  surface  speedily  becomes  covered  at  every  point  with  a 
sabulous  and  offensive  phosphatic  deposit.  If  the  loss  of  tissue  has 
been  extensive,  the  inverted  posterior  wall  of  the  bladder  protrudes 
in  a  semi-strangulated  condition,  and  is  more  or  less  incrusted  with 
the  same  deposit  and  bleeds  readily.  This  deposit  frequently  accu- 
mulates to  SQch  an  extent  in  the  vagina  that  the  woman  is  unable  to 
walk  or  even  to  stand  upright  without  suffering  great  agony. 

The  first  indication  is  to  remove  this  deposit  carefully,  as  far  as 
possible,  by  means  of  a  soft  sponge,  and  then  to  brush  the  raw  surface 
over  with  a  weak  solution  of  nitrate  of  silver.  If  at  any  point  the 
deposit  cannot  be  removed  at  first  without  causing  too  much  bleeding, 
the  deposit  itself  must  be  touched  with  the  same  solution  or  have  the 
solid  stick  applied  to  it.  Frequent  warm  sitz-baths  will  add  greatly 
to  the  comfort  of  the  sufferer.  The  vagina  must  be  washed  out  seve- 
ral times  a  day  with  large  quantities  of  warm  water.  Thi's  portion  of 
the  treatment  is  beyond  question  the  most  important  means  at  our 
command  for  restoring  the  parts  to  a  healthy  condition.  The  diffi- 
culty in  keeping  open  an  artificial  fistula  made  for  the  relief  of  cystitis, 
is  due  to  the  cleansing  measures  employed,  and  should  teach  us  a 
lesson  in  reference  to  the  treatment  of  accidental  fistulse.  In  artifi- 
cial fistulas  the  raw  edges  are  kept  in  a  healthy  condition  by  the  fre- 
quent use  of  the  injections,  and  free  from  the  irritation  always  exerted 
by  a  deposit  from  the  urine.  Whenever  this  is  done,  the  largest  sized 
artificial  opening  will  often  rapidly  close  of  itself.  Very  few  cases 
have  been  admitted  to  the  Woman's  Hospital  with  vesico-vaginal 
fistula  until  several  months  had  already  elapsed  after  receiving  the 
injury.  I  can  only  recall  tAvo  instances  where  women  were  sent  to 
the  hospital  Avith  this  lesion  immediately  after  delivery.  In  both  of 
these  cases  the  fistula  into  the  bladder  closed  within  a  month,  having 
had  no  treatment  but  the  warm-water  injections,  and  were  discharged 
cured  without  an  operation.  It  is  true  that  no  great  loss  of  tissue 
had  taken  place  in  either  case,  yet  the  openings  were  large  enough 
for  me  to  introduce  my  index  finger  through  them  into  the  bladder. 
One  of  these  cases  was  delivered,  I  believe,  by  Dr.  Emily  Blackwell, 


PREPARATORY  TREATMENT.  619 

in  consultation,  after  a  tedious  labor  due  to  a  contracted  pelvis.  The 
records  of  the  other  case  have  been  lost,  and  cannot  be  found  in  the 
hospital  books.  Case  XXV.,  in  the  "Abstract  of  Cases,"  is  one  of 
these,  and  is,  I  believe,  the  one  delivered  by  Dr.  Blackwell.  This 
woman  was  five  days  in  labor,  and  finally  delivered  by  forceps,  an 
opening  into  the  bladder  as  well  as  a  rectal  fistula  resulting.  The 
opening  into  the  bladder  closed  in  three  weeks,  and  the  retentive  power 
was  actually  gained  before  the  likelihood  of  such  an  occurrence  was 
ever  suspected.  She  ay  as  afterwards  admitted  for  the  cure  of  the 
rectal  fistula,  which  required  several  operations,  and  which,  from  its 
position,  had  not  been  so  much  benefited  by  the  injections. 

These  cases  certainly  teach  an  important  lesson,  and  my  experience 
in  the  use  of  hot-water  injections  leads  me  to  believe  that  if  they  be 
properly  employed,  many  of  these  openings  would  close  spontaneously, 
and  in  every  instance  the  sloughing  process  would  be  arrested.  This 
remark  is  applicable  to  all  other  injuries  dependent  on  childbirth,  and 
particularly  so  for  laceration  of  the  cervix,  a  large  proportion  of 
Avhich  would  be  healed  by  the  judicious  use  of  hot  water.  After  the 
sitz-baths  or  the  injections,  the  parts  must  be  thoroughly  dried,  and 
the  patient  be  protected  from  the  effects  of  the  urine  by  freely  anoint- 
ing the  outlet  of  the  vagina  and  neighboring  surfaces  with  some  simple 
ointment  of  a  proper  consistency.  The  napkins  particularly  must  be 
well  washed  when  saturated  with  urine,  and  not  simply  dried  before 
being  used  again.  Time  and  increased  comfort  to  the  patient  will  be 
gained  by  proper  attention  to  such  details. 

The  urine  is  almost  always  phosphatic,  and  must  be  kept  in  an 
acid  condition  or  there  will  be  no  local  improvement.  The  follow- 
ing agents  I  have  generally  used  for  this  purpose :  two  drachms  of 
benzoic  acid,  and  three  drachms  of  borax  to  twelve  ounces  of  water, 
of  which  a  tablespoonful,  further  diluted,  should  be  given  three  or 
four  times  a  day.  After  the  urine  has  become  acid,  the  dose  must 
be  reduced  to  the  smallest  quantity  by  which  the  acidity  can  be 
maintained,  so  as  to  avoid  deranging  the  digestion.  At  the  same 
time  diluents  must  be  freely  employed  so  as  to  render  the  urine  less 
irritating. 

About  every  fifth  day,  the  excoriated  surfaces  yet  unhealed  should 
be  protected  by  an  application  of  the  solution  of  nitrate  of  silver.  It 
is  often  necessary  to  pursue  the  same  general  course  for  many  weeks 
before  the  parts  can  be  brought  into  a  healthy  condition.  This  state 
is  not  reached  until  not  only  the  vaginal  wall  but  also  the  hypertro- 


620 


VESICO-   AND    RECTO-VAGINAL    FISTULA. 


phied  and  indurated  edges  of  the  fistula  have  attained  a  natural  color 
and  density.  This  is  the  secret  of  success,  but  it  is  one  which  is 
rarely  appreciated,  and  yet  without  it,  the  most  skilfully  performed 
operation  will  almost  certainly  fail. 

When  the  proper  condition  has  been  brought  about,  the  surgeon 
may  then  be  able  to  decide  upon  some  definite  plan  of  procedure  for 
closing  the  fistula.  After  placing  the  patient  on  the  side  and  intro- 
ducing the  speculum,  the  edges  of  the  opening  should  be  seized  at 
opposite  points  with  a  tenaculum  held  in  each  hand,  and  the  degree  of 
tension  judged  of  by  approximating  the  edges  in  different  directions. 


Fig.  106. 


A  vesico- vaginal  fistula,  speculum  and  tonacula  in  situ. 

If  at  any  point  they  do  not  come  readily  together,  the  finger  can 
detect  the  seat,  of  resistance  while  the  parts  are  kept  on  the  stretch 
by  a  tenaculum.  When  the  bands  are  comparatively  slight  and 
superficial,  or  are  brought  Avell  up  by  traction,  it  is  generally  sufficient 
to  divide  thcra  with  scissors  at  the  time  of  the  operation  for  closure. 
But,  on  the  contrary,  when  the  tension  is  due  to  extensive  sloughing, 
or  when  the  posterior  cul-de-sac  has  been  destroyed,  the  parts  can 


PREPARATORY    OPERATIOX.  021 

seldom  be  properly  freed  without  more  or  less  lieraorrliagc  following, 
and  it  will  be  necessary  to  do  one  or  more  preparatory  o})crations. 

By  placing  the  patient  on  the  back,  with  two  fingers  of  the  left 
hand,  as  a  guide,  introduced  into  the  rectum,  and  the  thumb  or  index 
finger  of  the  same  hand  into  the  vagina,  to  make  counter-pressure, 
point  after  point  can  be  snipped  with  a  pair  of  blunt-pointed  scissors. 
This  can  be  done  to  any  extent  without  using  the  speculum,  and  with- 
out fear  of  entering  either  rectum  or  bladder,  if  the  position  of  the 
uterus  can  be  recognized,  but  the  fingers  in  the  rectum  should  be  used 
as  a  guide,  and  a  sound  should  be  held  by  an  assistant  in  the  bladder 
if  necessary.  When  the  exact  position  of  the  uterus  cannot  be  de- 
tected, Douglas's  cul-de-sac  may  be  easily  entered.  This  accident 
has  happened  to  me  several  times,  but  without  any  evil  consequences. 
When  it  occurs  I  immediately  introduce  the  necessary  number  of 
sutures  to  close  the  wound,  and  then  place  the  woman  in  bed  to  be 
treated  as  if  a  fistula  had  been  closed. 

After  opening  up  the  vagina,  as  freely  as  may  be  deemed  prudent 
at  the  time,  one  of  Sims's  glass  vaginal  plugs  (Fig.  107)  should  be  in- 

Fiff.  107. 


Sims's  vaginal  glass  plug. 

troduced  and  secured  in  place  by  means  of  a  T  bandage.  It  should 
be  only  just  long  enough  to  put  the  canal  well  on  the  stretch,  but  not 
sufficient  to  produce  sloughing  or  pelvic  inflammation.  The  bleeding 
is  sometimes  excessive,  but  is  generally  controlled  by  the  plug,  and  as 
the  instrument  is  hollow  and  transparent,  it  possesses  the  advantage  of 
a  speculum  in  exposing  the  parts  to  view.  If  the  blood,  however, 
should  begin  to  escape,  it  can  be  controlled  by  introducing,  with  a  pair 
of  dressing  forceps,  portions  of  damp  cotton  along  the  slight  depression 
in  the  plug  made  for  the  urethra ;  then  the  instrument  can  be  rotated 
until  the  outlet  of  the  vagina  has  been  by  this  means  encircled  by  a 
tampon.  It  is  remarkable  how  much  absorption  of  the  cicatricial 
tissue  takes  place  in  a  few  weeks,  when  judicious  pressure  has  been 
maintained  by  this  instrument.  Scissors  are  much  to  be  preferred  to 
the  knife  in  dividing  these  bands.  Cicatricial  tissue  can  be  lacerated 
or  divided  by  scissors  with  far  less  risk  of  inflammation,  and  with 


622  VESICO-   AND    RECTO-VAGINAL    FISTULA. 

certainly  less  hemorrhage  than  follows  the  use  of  the  knife,  and  the 
parts  do  not  heal  so  rapidly  when  scissors  are  used,  so  that  time  is 
gained  wherein  to  bring  about  absorption. 

After  an  operation  of  this  kind  the  patient  should  be  lifted  into  bed, 
to  remain  there  for  a  week  or  ten  days.  The  feet  should  be  kept 
warm,  opium  administered  freely  if  needed,  and  hot  applications  made 
to  the  abdomen  upon  any  threat  of  inflammation.  The  urine  must  at 
first  be  drawn  by  the  catheter,  and  without  removing  the  plug,  so  as 
not  to  excite  hemorrhage.  As  the  patient  lies  on  the  back,  the  limbs 
are  to  be  flexed  over  the  abdomen,  thus  exposing  the  mouth  of  the 
urethra,  and  the  catheter  can  then  be  readily  passed  along  the  canal 
without  being  compressed.  As  soon  as  suppuration  begins  the  plug 
will  become  loosened,  and  it  will  then  be  safe  to  remove  it.  At  once 
injections  of  warm  water  with  a  little  old  castile  soap  added  must  be 
employed,  and  frequently  if  the  discharge  becomes  profuse.  After 
the  parts  have  been  properly  healed,  if  necessary,  the  operation  for 
enlarging  the  canal  must  be  repeated  until  the  object  in  view  has  been 
attained. 

Operation  for  Closing  a  Fistula. — The  bowels  are  to  be  thoroughly 
acted  upon  by  a  cathartic,  and  if  necessary  by  an  enema,  immediately 
before  the  operation. 

The  patient  ought  to  be  dressed  in  a  night-gown  and  drawers,  and 
have  the  abdomen  free  from  any  constriction  about  the  waist. 

It  is  customary  to  use  an  ansesthetic,  although  a  dose  of  opium  is 
quite  sufficient  to  relieve  any  pain  the  patient  is  likely  to  suffer 
under  ordinary  circumstances,  if  the  vagina  is  free  from  cicatricial 
tissue. 

Dr.  Simon  operated  with  the  patient  on  the  back,  using  generally 
three  retractors;  one  to  draw  down  the  perineum,  and  two  to  enlarge 
laterally  the  outlet  of  the  vagina.  Pie  also  had  an  assistant  on  each 
side.  Dr.  Bozeman  employs  an  apparatus  on  Avhich  the  patient  is 
somewhat  in  the  knee  and  chest  position.  It  has  the  advantage 
sometimes,  that  the  operation  can  be  performed  by  the  operator  with 
but  little  assistance.  When  the  fistula  is  close  behind  either  ramus, 
or  in  a  fat  subject,  it  is  almost  impossible  to  bring  the  parts  into  view 
unless  the  woman  be  placed  on  the  knees  and  chest.  As  this  position 
is  an  exceedingly  tiresome  one,  the  patient  will  recaive  much  support 
from  Bozeman's  apparatus.  But  having  accustomed  myself  to  another 
method,  I  find  this  one  fatiguing. 

I  prefer  the  table,  which  has  been  described  for  making  the  ordi- 
nary examinations.     The  position  on  the  left  side  leaves  the  operator 


MODE    OF    CL0SINC5    A    FISTULA.  623 

free  to  be  seated,  and  it  is  very  rare  that  I  find  any  other  one  is 
called  for.  If  the  patient  be  covered  by  a  sheet,  drawers,  and  under- 
shirt, her  night-gown  may  be  slipped  up  around  the  waist,  so  as  to 
prevent  it  from  becoming  soiled,  and  this  should  be  arranged  before- 
hand by  a  nurse  or  female  attendant. 

The  proper  position  for  the  patient  has  been  fully  described  else- 
where. 

Plaving  decided  on  the  direction  for  closing  the  fistula,  and  having 
thoroughly  freed  the  flaps,  its  edges  are  then  to  be  freshened  or  de- 
nuded. At  the  most  depending  point  the  edge  is  to  be  caught  up 
with  a  tenaculum,  and  cut  away  along  the  inner  border  in  a  continuous 
strip.  It  will  require  but  little  practice  to  remove  this  in  a  single 
strip  entirely  around  the  opening.  If  the  denuded  surface  is  then 
not  of  sufficient  Avidth,  another  strip  can  be  removed  just  outside  of  it. 
The  freshened  surface  should  be  extended  as  near  to  the  mucous  mem- 
brane of  the  bladder  as  possible,  Avithout  involving  it. 

It  was  Prof.  Simon's  practice  to  include  the  vesical  mucous  membrane 
freely.  When  this  is  done  even  by  accident,  there  is  always  a  large 
amount  of  blood  lost.  In  my  own  practice  this  accident  has  occurred 
tAvice,  and  on  both  occasions,  the  bladder  became  so  distended  by  a 
clot  that  it  Avas  necessary  to  remove  the  sutures  to  arrest  the  bleeding. 
Dr.  Peaslee,  a  short  time  before  his  death,  lost  a  patient  in  the 
Woman's  Hospital  from  hemorrhage  after  this  accident.  The  sm-face 
retracted  from  the  edge,  and  he  found  it  impossible  to  detect  the  point 
of  bleeding,  or  to  arrest  it  by  injection.  I  did  not  see  this  case, 
which  was  evidently  an  unusual  one.  I  have  been  able  in  some 
cases  to  exert  pressure  by  pushing  a  portion  of  a  thin  handkerchief 
through  the  fistula ;  then,  as  the  ends  Avere  held,  a  sufficient  quantity 
of  cotton  Avas  packed  into  the  bag  thus  formed.  This  made  a  mass  in 
shape  like  a  door-knob,  which  Avould  press  against  the  bleeding  surface 
Avhen  traction  was  made  on  the  portion  of  the  handkerchief  outside  of 
the  fistula.  Under  ordinary  circumstances  the  bleeding  can  be  arrested 
by  means  of  a  suture  passed  from  the  vagina,  through  the  septum  into 
the  bladder,  then  across  to  some  distance  on  the  other  side,  and  then 
out  into  the  vagina  again.  In  this  Avay,  the  bleeding  vessel,  which 
comes  from  the  neck  of  the  uterus,  or  from  the  neck  of  the  bladder,  is 
ligated,  as  it  were,  and  the  bleeding  is  arrested.  One  precaution, 
hoAvever,  must  be  taken,  to  avoid  including  the  ureters,  and  this  can 
be  done  by  passing  the  suture  at  a  less  distance  than  half  an  inch  on 
either  side  from  the  median  line.  It  is  almost  of  as  great  importance 
to  obtain  a  broad  surface  for  union,  as  to  free  the  parts  from  traction. 


624 


VESICO-    AND    RECTO-VAGINAL    FISTULA, 


As  the  edges  are  generally  too  thin  after  the  tissues  have  been 
destroyed  by  sloughing,  it  will  be  necessary  to  extend  the  denuded 
surface  on  to  the  vaginal  wall,  or  to  split  the  edges  to  a  certain  depth. 
The  former  plan  is  the  one  usually  adopted.  To  bring  these  surfaces 
up  in  a  fold  together  renders  it  all  the  more  necessary  that  the  parts 
should  have  been  freed  from  tension.  When  this  plan  is  followed  it 
has  been  asserted  that  the  edges  are  rolled  into  the  bladder,  but  this 
is  not  true,  since  the  sutures  are  always  introduced  at  the  edge  of  the 
mucous  membrane  of  the  bladder,  so  that  surface  must  be  brought 
into  apposition,  and  no  tissue  can  be  turned  in.  The  operation,  how- 
ever, is  never  more  than  partially  successful,  unless  the  precaution 
be  taken  to  extend  the  freshened  surface  some  distance  beyond  each 
angle  of  the  fistula,  until  the  folds  which  are  formed  become  lost  on 
the  vaginal  level.  Let  the  reader  pinch  up  two  small  folds  of  a 
napkin  together,  when  it  will  be  easily  seen  that  these  have  to  be 
extended  to  some  distance  before  they  can  be  smoothed  down  to  the 
common  surface.  When  the  necessity  for  extending  these  folds  has 
not  been  appreciated,  the  operation  is  always  exceedingly  liable  to 
fail,  on  account  of  a  small  opening  being  left  at  each  angle. 

I  have  already  described  the  manner  of  introducing  the  needles, 
each  armed  with  a  silk  loop,  into  which  the  wire  is  to  be  hooked. 
Also  the  mode  of  twisting  these  sutures  is  given,  and  of  bringing  the 
parts  together.  These  rules  are  all  applicable  to  the  general  use  of 
silver  sutures,  but,  in  connection  with  the  present  subject,  it  would  be 
advisable  for  the  reader  again  to  refer  to  the  chapter  descriptive  of 
their  use. 


Fig.  108. 


Sims's  self-retaining,  or  sigmoid,  catheter. 


After  completing  the  operation,  the  patient  is  to  be  turned  gently 
on  the  back,  and  a  catheter  introduced.  If  the  urine  be  discolored, 
a  quantity  of  tepid  water  must  be  injected  into  the  bladder  for  the 
purpose  of  washing  out  any  blood  which  may  have  accumulated  there. 


SIGMOID    CATHETER.  625 

To  Sims's  sigmoid,  or  self-retaining,  catheter  I  am  satisfied  that  we 
are  greatly  indebted  for  success  in  this  operation,  as  well  as  for  much 
comfort  which  it  aflfords  the  patient.  It  should  be  made  of  block  tin, 
that  the  curve  may  be  altered  to  suit  each  individual  case.  It  should 
not  touch  the  fundus  of  the  bladder,  yet  it  ought  to  be  of  sufficient 
length  to  properly  balance  in  the  urethra,  and  to  lie  close  up  behind 
the  pubes.  When  the  fundus  of  the  bladder  rests  on  the  point  of  the 
catheter,  as  it  often  does  Avhen  the  instrument  is  not  properly 
balanced,  it  must  be  withdrawn,  and  the  necessary  change  made  in 
its  shape.  A  want  of  attention  to  this  point  will  lead  to  much  irrita- 
tion of  the  bladder,  and  will  cause  a  failure  of  the  operation.  Per- 
foration of  the  bladder  and  death  may  result  from  neglect  of  this,  as 
I  have  known  to  happen  in  one  instance. 

The  catheter  is  generally  made  five  inches  long  before  being  bent 
to  the  proper  curve;  a  greater  length,  however,  is  necessary  if  the 
patient  is  unusually  fat.  As  a  receptacle  for  the  urine,  a  large-sized 
oval  cup  may  be  used,  such  as  are  found  in  bird  cages,  or  one  of  any 
other  convenient  shape.  The  catheter  must  be  removed  several  times 
a  day  for  the  purpose  of  cleaning  it ;  this  is  done  by  forcing  a  stream 
of  water  through  it  from  a  large  syringe.  The  patient  should  be 
instructed  to  notice  carefully  that  the  urine  escapes  freely  at  all 
times.  It  is  well  to  have  two  catheters,  so  that  one  may  be  intro- 
duced immediately  on  the  removal  of  the  other. 

The  patient  must  lie  on  the  back  for  the  greater  part  of  the  time, 
and,  if  possible,  preserve  this  position  until  the  sutures  shall  have 
been  removed.  It  will  add  greatly  to  her  comfort  to  have  a  double 
inclined  plane,  well  padded,  to  support  the  lower  limbs  Avhen  drawn 
up,  and  this  can  be  removed  from  time  to  time,  so  that  the  legs  may 
be  stretched  at  full  length  for  change  of  position.  The  support  should 
be  open  at  the  ends,  and  a  portion  of  the  side  be  removed,  so  as  not 
to  interfere  with  the  catheter. 

A  sufficient  quantity  of  opium  should  be  administered  daily  to  keep 
the  bowels  constipated  until  the  sutures  are  removed,  and  the  diet 
may  be  a  generous  one,  but  should  be  regulated  with  the  view  to 
cause  no  disturbance  of  the  bowels. 

The  sutures  are  generally  removed  on  the  eighth  or  tenth  day,  and 
in  the  manner  already  described.  Twelve  hours  afterwards  a  dose 
of  castor  oil  should  be  given.  The  catheter  must  be  continued  in  use 
for  a  few  days  longer,  according  to  circumstances,  and  after  the  four- 
teenth or  the  twentienth  day  the  patient  may  sit  up. 
40 


626  DIFFERENT    FORMS     OF    FISTULiE, 


CHAPTER   XXXII. 

DIFFERENT  FORMS  OF  FISTULiE. 
Vesico-vaginal — Urethro-vaginal — Ureto-vaginal — Recto-vaginal. 

No  classification  can  be  made  of  these  injuries  which  would  not  be 
an  arbitrary  one,  if  based  on  their  location  alone.  A  general  classifi- 
cation can  be  made  up  of  vesico-vaginal,  urethro-vaginal,  ureto-vagi- 
nal, and  the  recto-vaginal  fistulse.  Beyond  this,  however,  a  system 
based  on  the  location  of  the  injury  is  the  only  one  which  would 
indicate  clearly  the  various  forms  of  vesico-vaginal  fistulge. 

Mv  main  object  is  to  present  these  lesions  as  the  result  of  various 
injuries,  but  I  shall  also  point  out  the  congenital  conditions  simulating 
them.  The  classification,  therefore,  will  be  in  a  general  way  made 
from  the  point  of  view  of  the  location  of  the  fistulge,  Avith  some 
reference,  however,  to  the  frequency  of  their  occurrence,  and  the 
following  order  is  adopted  : — 

1.  Loss  of  tissue,  confined  to  the  base  of  the  bladder. 

2.  Injuries  of  the  cervix  uteri  and  posterior  cul-de-sac,  the  fistula 
being,  as  a  rule,  in  the  upper  part  of  the  vagina,  although  sometimes 
the  whole  base  of  the  bladder  is  also  involved. 

3.  Loss  of  tissue  at  the  lower  portion  of  the  vagina,  extending  to 
one  ramus  or  to  both. 

4.  Sloughing  or  laceration  at  the  neck  of  the  bladder. 

5.  Injuries  to  the  urethra  and  defective  development. 

6.  The  ureter  opening  into  the  vagina,  as  the  result  of  injury  or  as 
a  congenital  defect. 

7.  Openings  into  the  rectum  from  the  vagina. 

8.  Vesico-vaginal  fistula  from  accidental  causes. 

1.  A  loss  of  tissue  confined  to  the  base  of  the  bladder  constitutes 
the  most  simple  form  of  fistula.  It  is  fairly  shown  in  Fig.  106,  which 
represents  a  case  m  which  the  neck  of  the  bladder  near  the  cervix 
uteri  is  involved.  In  such  a  case,  inasmuch  as  the  sloughing  has  been 
confined  simply  to  the  tissues  lost,  it  will  generally  be  easy  to  approxi- 
mate the  edges  of  the  fistula  in  any  direction.  Whenever  a  choice 
exists,  the  line  of  union  should  always  be  extended  in  the  long  axis  of 


VESICAL    FISTULA    INVOLVING    THE    CEKVIX    UTERI.       627 

the  vagina  and  not  across  the  passage,  since  this  ayouM  have  the  effect 
of  drawing  down  the  uterus  more  or  less.  This  might  result  in  a  form 
of  retroversion  very  difficult  to  correct.  Under  other  circumstances, 
■where  great  loss  of  tissue  has  occurred,  it  l)ecomes  necessary  to  draw 
down  the  uterus,  and  it  remains  permanently  retroverted,  but  no 
special  difficulty  results  from  this,  since  the  uterus  will  occupy  the 
position  of  the  tissue  lost.  The  treatment  of  these  simple  cases  re- 
quires no  further  direction,  since  it  has  been  already  fully  detailed 
in  the  general  description. 

2.  Injury  of  the  cervix  uteri  and  posterior  cul-de-sac,  the  fistula 
being,  as  a  rule,  in  the  upper  portion  of  the  vagina,  although  some- 
times the  whole  base  of  the  bladder  is  also  involved.  Such  an  injury 
results  from  laceration  and  from  sloughing  caused  by  the  presenting 
portion  of  the  child  while  it  is  yet  above  the  superior  strait.  Ante- 
rior lacerations  of  the  cervix  directly  in  the  median  and  extending 
into  the  bladder  are  the  varieties  most  frequently  found.  Some- 
times a  lateral  laceration  of  the  cervix  on  one  side,  extending  into  the 
bladder,  seems  to  have  been  formed.  But  I  am  inclined  to  regard 
these  lacerations  as  first  occurring  in  the  median  line,  and  from  in- 
flammation or  sloughing  about  the  cul-de-sac  being  displaced  to  one 
side.  This  complication,  involving  the  cervix,  is  of  more  frequent 
occurrence  among  those  who  have  borne  a  number  of  children  and 
have  the  abdominal  parietes  much  relaxed,  than  it  is  among  primipara. 
The  cause  may  be  suspected,  therefore,  to  be  due  somewdiat  to  rigidity 
of  the  OS  and  an  anterior  obliquity  of  the  uterus. 

In  these  cases  there  is  almost  always  some  effort  of  nature  to  repair 
the  injury.  The  laceration  through  the  base  of  the  bladder  is  gene- 
rally found  to  have  been  partially  closed  by  granulation,  and  that  of 
the  cervix  uteri  entirely  so.  Occasionally,  the  whole  line  will  be 
found  bridged  over,  leaving  only  a  fistulous  tract  at  the  bottom  of  the 
original  fissure,  opening  into  the  cervical  canal  a  little  above  the  line 
of  junction  with  the  vagina,  as  showm  in  Fig.  109,  from  A  to  B.  Some- 
times the  laceration  extends  not  only  into  the  base  of  the  bladder 
from  the  anterior  lip,  but  backward  through  the  posterior  one.  In 
these  cases  the  opening  into  the  bladder  may  close,  leaving  only  a 
small  fistula  against  the  uterine  wall,  while  the  tear  through  the 
cervix  remains  ununited.  Occasionally  the  tear  both  in  the  cervix  and 
the  vesico-vaginal  septum  will  close  from  each  end,  thus  leaving  a 
small  opening  in  front  of  the  cervix,  as  shown  in  Fig.  110. 

The  passage  by  which  the  urine  escapes  from  the  bladder  into  the 
uterine  canal,  as  shown  in  Fig.  109,  can  be  remedied  only  by  repro- 


628 


DIFFERENT  FORMS  OF  FISTULA. 


ducing  the  original  condition  of  the  injury.      This  necessity  has  been 
long  recognized,  but  no  one,  so  far  as  my  knowledge  extends,  ever 


Ficr.  109. 


Fistnlous  tract  after  healing  of  a  laceration. 
Fig.  110. 


Small  fistula  in  front  of  the  cervii 


realized  the  true  cause  of  the  lesion  until  I  described  it  as  a  result  of 
a  laceration  of  the  cervix  which  had  healed  over  from  above,  leaving 


MODE    OF    CLOSING    A    VES ICO-UTER  IN  E    SINUS.  629 

the  sinus  below.  It  was  thought  that  a  slough  took  place,  but  this  is 
impossible,  since,  under  all  circumstances,  the  wall  of  the  bladder  is 
subjected  to  the  same  degree  of  pressure,  and  would  be  equally 
injured.  The  bladder  becomes  necessarily  interposed  between  the 
presenting  portion  of  the  child  and  the  bony  walls  of  the  pelvis,  so 
that  the  uterine  tissues  could  not  be  injured  without  the  coats  of  the 
bladder  being  damaged,  even  to  a  greater  extent. 

I  have  occasionally  met  with  cases  in  which  a  probe  could  be  passed 
from  the  bladder  along  the  sinus  A  B,  Fig.  109,  until  brought  into  con- 
tact with  a  sound  in  the  uterine  canal ;  but  these  are  exceptional. 
The  proper  mode  of  operating  is  to  divide  the  cervix  in  the  median 
line  with  a  pair  of  scissors,  through  to  the  vaginal  junction  ;  then,  by 
means  of  a  blunt  hook,  the  mouth  of  the  sinus  at  A,  Fig.  109,  must  be 
found,  after  which  the  completion  of  the  operation  becomes  simple. 
The  whole  tract  of  the  sinus  must  be  laid  open,  and  its  walls  must  be 
removed  in  a  single  strip,  from  A  to  B,  which  may  be  done  with  a 
pair  of  scissors  or  with  a  small  scalpel,  first  catching  up  one  end  of 
the  sinus  with  a  tenaculum.  A  long,  straight  needle  is  used  to  carry 
the  suture,  and  the  flaps  are  held  widely  separated,  so  as  to  straighten 
out  the  course  of  the  sinus,  which  greatly  facilitates  the  passage  of 
the  needle.  But  it  is  by  no  means  an  easy  matter  to  accomplish  this, 
since,  without  great  care,  the  needle  will  be  broken  off,  leaving  a  por- 
tion buried  in  the  uterine  tissues.  The  point  at  which  the  needle  is 
to  be  introduced  must  be  caught  up  with  a  strong  tenaculum,  in  order 
to  steady  the  parts,  and  the  needle,  as  it  is  gradually  forced  through, 
must  be  seized  and  urged  on,  close  up  to  its  pohit  of  entrance  with 
the  tissues.  When  the  tissues  are  more  than  usually  dense,  it  is 
often  necessary  to  employ  a  lance-pointed  needle  or  one  having  a 
cutting  edge.  A  straight  needle,  or  one  nearly  so,  is  the  only  one 
which  can  be  directed  with  any  certainty.  Each  suture  must  pass 
beneath  the  course  of  the  sinus,  or  the  urine  will  again  find  its  way 
into  the  uterine  canal.  The  operation  and  after-treatment  are  in 
every  respect  the  same  as  for  laceration  of  the  cervix. 

Usually  it  will  be  difficult  to  bring  the  edges  of  the  fistula  together 
without  removing  a  portion  of  the  cervix,  and  it  may  be  necessary  to 
take  out  a  V  shaped  portion  without  going  through  to  the  canal,  and 
then  to  freshen  the  edges  of  the  fistula  and  the  vaginal  surface  over 
a  space  equal  to  that  represented  within  the  dotted  lines.  Fig.  110. 
The  necessity  for  extending  the  freshened  surface  to  such  a  distance 
from  the  angle  of  the  fistula,  has  already  been  explained,  and  it  is 
particularly  necessary  in  this  location  on  account  of  the  great  liability 


630  DIFFERENT    FORMS    OF    FISTULA. 

to  a  sinus  being  formed  from  each  end.  The  sutures  should  be  in- 
troduced transverse  to  the  axis  of  the  vagina,  and,  if  necessary  to 
relieve  the  parts  from  tension,  thev  should  be  freed  by  snipping  with 
a  pair  of  scissors,  to  a  proper  depth,  the  tissues  on  each  side  in 
a  direction  represented  by  the  dotted  lines  A  B  and  A'  B',  Fig. 
110. 

Whenever  the  cervix  has  been  lost  from  sloughing,  the  posterior 
cul-de-sac  rarely  escapes  without  extensive  injury.  If  it  so  happens 
that  the  fistula  is  small  and  situated  at  the  median  line,  it  may  not  re- 
quire any  operative  interference,  but  the  woman  may  suifer  indirectly. 
After  the  cervix  has  sloughed  away,  it  is  a  very  frequent  occurrence  for 
the  uterus  to  have  been  damaged  to  such  an  extent  that  menstruation 
ceases,  and  atrophy  takes  place.  The  effect  is  the  same  as  if  a  change 
of  life  had  ensued,  and  this  is  brought  about  without  reference  to  the 
age  of  the  woman.  I  have  known  of  sevei'al  instances  Avhere  this  has 
occurred  after  the  birth  of  a  first  child,  and  all  the  women  were  under 
thirty  years  of  age. 

When  the  sloughing  is  in  the  upper  part  of  the  vagina,  the  inflam- 
mation frequently  extends  to  the  bottom  of  Douglass's  cul-de-sac,  with 
the  effect  of  retroverting  the  uterus,  and  not  seldom  binding  it  down 
in  the  retroverted  position.  We  have  seen  that  the  presence  of  cica- 
tricial tissue  in  this  neighborhood,  and  in  the  cervix,  produces  more 
or  less  disturbance  of  the  nervous  system,  and  that  it  frequently  has 
a  marked  and  deleterious  effect  on  nutrition,  and  keeps  up  a  condition 
of  anaemia .  Much  cicatricial  tissue  is  also  a  serious  complication 
as  regards  the  surgical  procedure.  When  the  cul-de-sac  is  filled  by 
cicatricial  tissue,  traction  is  exerted  on  the  edges  of  the  fistula  when- 
ever it  extends  laterally  beyond  the  width  of  the  cervix.  The  result 
is  to  draw  one  or  both  of  the  angles  upward,  giving  a  crescent  shape 
to  the  fistula,  and  exerting  so  much  traction  on  the  central  portion 
that  it  is  exceedingly  difficult  even  to  approximate  its  edges. 

Occasionally,  even  after  the  greatest  destruction  of  tissue,  the 
cicatricial  bands  dragging  the  edges  back  into  an  angle  on  each  side 
of  the  remains  of  the  cervix,  may  be  easily  divided  at  the  time  of  the 
operation.  I  have  had  a  number  of  cases  where  after  dividing  these 
bands  the  edges  could  be  brought  together  in  the  median  line  without 
shortening  the  vagina.  In  some  instances  the  line  of  union  may  be 
made  oblique.  But  the  most  common  procedure  is  to  freely  divide 
the  tissue  filling  up  the  cul-de-sac,  and  then  to  bring  about  a  modifying 
effect  by  the  use  of  a  glass  plug.  This  operation  may  have  to  be 
repeated,  and  the  use  of  the  plug  continued  until  the  neck  of  the  uterus 


LARGE    FISTULA    OF    BASE    OF    THE    BLADDER. 


631 


becomes  movable.  The  fistula  is  then  closed  by  drawing  down  the 
neck  of  the  uterus  and  uniting  it  to  the  neck  of  the  bladder.  The 
result  is  that  the  vagina  becomes  very  much  shortened,  and  the  uterus 
retroverted,  but  the  latter  condition,  in  consequence  of  the  great  loss 
of  tissue,  causes  little  or  no  disturbance. 

Cicatricial  tissue  can  sometimes  be  utilized  as  in  the  following 
case. 

Case  XLV. — Mrs.  W.,  was  sent  to  the  Woman's  Hospital  Oct. 
1864,  by  Dr.  Frank  11,  Hamilton.  The  previous  history  of  the  case 
will  be  found  in  the  "  Abstract  of  Cases"  (No.  34).  The  entire  base 
of  the  neck  of  the  bladder  had  been  lost,  and  a  portion  of  the  anterior 
lip  of  the  uterus,  as  shown  in  Fig.  111.  The  posterior  wall  and 
fundus  of  the  bladder  protruded  through  the  fistulous  opening  into  the 

Fig.  111. 


Fistula,  involving  the  ■whole  base  of  the  bladder. 


vagina.  The  cervix  was  surrounded  by  cicatricial  tissue,  and  its 
posterior  lip  was  blended  with  a  mass  of  the  same  character  filling  up 
the  cul-de-sac.     The  bands  were  more  dense  to  the  right  side,  and, 


632  DIFFERENT    FORMS    OF    FISTULA.. 

spreading  over  the  lateral  wall  of  the  vagina,  extended  forward  along 
the  sulcus,  so  as  to  involve  a  portion  of  the  anterior  lip  of  the  fistula. 
By  the  tension  thus  exerted  the  fistula  was  drawn  obliquely  across  the 
axis  of  the  vagina,  carrying  the  angle  on  the  right  side  into  the  cul- 
de-sac,  somewhat  posterior  to  the  cervix  uteri.  When  the  patient 
was  placed  on  the  knees  and  elbows,  the  fistula  presented  the  appear- 
ance indicated  in  Fig.  Ill,  being  more  than  three  inches  in  length, 
and  over  an  inch  in  breadth  in  its  widest  diameter  between  the  cervix 
uteri  and  the  neck  of  the  bladder.  At  each  extremity  of  the  fistula 
the  edges  were  shelving,  so  as  to  narrow  somewhat  the  opening  on 
the  bladder  surface.  The  mouth  of  the  ureter  on  each  side  could  be 
seen  in  the  edge  of  the  fistula  at  A  and  B.  The  uterus  was  almost 
immovable,  Avhile  the  anterior  lips  of  the  fistula,  in  the  neighborhood 
of  the  neck  of  the  bladder  was  quite  free.    The  urethra  was  uninjured. 

At  the  operation  the  cervix  was  freed  of  its  adhesions  behind,  so 
that  it  could  be  readily  drawn  down  to  the  neck  of  the  bladder.  The 
division  was  extended  well  towards  A,  and,  in  the  direction  B,  nearly 
to  the  angle  of  the  fistula  on  that  side.  It  was,  however,  purposely  not 
carried  entirely  aci'oss  the  vagina,  in  order  that  the  remaining  portion  of 
the  band  running  from  the  cul-de-sac  along  the  anterior  lip,  D  C,  might, 
by  its  ti'action,  keep  the  edges  of  the  fistula  together,  free  from  strain, 
after  the  sutures  were  twisted.  But  before  this  force  could  be  brought 
into  action  it  was  necessary  to  separate  the  attachment  of  this  band 
freely  in  the  direction  CD,  from  the  neighboring  cicatricial  tissue  on 
the  lateral  wall  of  the  vagina.  As  soon  as  this  was  done,  that  side 
of  the  fistula  was  drawn  nearly  over  to  the  neck  of  the  uterus,  and  the 
opposite  edges  could  be  brought  together,  free  from  tension  at  any 
point.  As  the  bladder  protruded  through  the  fistula,  so  as  to  obscure 
it  entirely  when  the  patient  was  placed  on  the  left  side,  it  was  neces- 
sary to  perform  every  step  of  the  operation  on  the  knees  and  elbows, 
and  nearly  two  hours  were  required.  With  the  exception  of  the  shelv- 
ing portion  at  each  angle  of  the  fistula,  no  other  part  of  its  edge  was 
included  in  the  line  of  freshening.  It  was  extended  a  little  outside  on 
the  vaginal  surface,  and  across  the  cervix  uteri  in  front  of  the  os.  A 
more  uniform  or  reo-ular  line  was  thus  obtained,  aiid  the  cicatricial 
edges  of  the  fistula  were  avoided.  The  cervix  uteri  was  attached  a 
little  to  the  right  of  the  neck  of  the  bladder,  and  when  the  operation 
was  completed,  owing  to  the  traction  exerted  by  the  undivided  portion 
of  the  band  extending  from  the  cul-de-sac  in  the  direction  beyond  the 
point  D,  the  line  of  union  was  somewhat  oblique,  but  at  the  same  time 
nearly  in  the  axis  of  the  vagina. 

Ten  days  afterwards,  on  examination,  every,  portion  of  the  line  was 
found  perfectly  united  ;  but,  in  consequence  of  its  great  length,  it  was 
deemed  advisable  to  leave  the  sutures  in  a  few  days  longer.  During 
the  night  the  woman  became  intoxicated  through  the  kind  offices 
of  some  outside  friends,  and  was  on  licr  feet  for  several  hours.  In 
the  morning,  the  urine  was  found  esca])ing  freely  from  an  opening 
formed  by  the  tearing  out  of  the  last  suture  in  the  angle  on  the  right 
side,  and  was  large  enough  to  admit  readily  the  point  of  a  sound. 


-     VESICO-VAGINAL    FISTULA.  633 

She  was  discharged  for  disorderly  conduct,  but  Avas  subsequently  re- 
admitted and  cured. 

This  case  beautifully  illustrates  a  mode  of  procedure  of  which  I 
always  avail  myself  when  possible.  It  aims  to  utilize  the  line  of 
tension  exerted  by  tlie  cicatricial  tissue,  so  that  it  will  contribute  di- 
rectly towards  approximating  the  edges  of  the  wound,  and  thus  aid  in 
relieving  a  strain  which  might  otherwise  be  too  great  for  the  sutures 
to  bear.  I  am  satisfied  that  this  case  could  not  have  been  cured  by 
any  other  method.  Another  point  of  interest  is  that  tlic  edges,  re- 
quiring eighteen  sutures,  presented  the  longest  continuous  line  I  have 
ever  seen  brought  together  in  the  vagina,  with  a  single  exception. 
This  was  a  case  in  the  hospital,  in  which  the  child's  head  had  passed 
into  the  rectum,  lacerating  the  whole  recto-vaginal  septum  from  the 
cul-de-sac  through  the  sphincter  ani  and  perineum.  The  rent  was 
closed  by  twenty-three  sutures  in  the  vagina,  and  five  through  the 
perineum,  with  the  result  that  it  united  throughout.  But  in  this  case 
there  had  been  no  sloughing,  and  the  edges  within  the  vagina  lay 
almost  in  contact. 

I  have  in  two  instances  closed  the  os  when  a  condition  existed  like 
that  represented  in  Fig.  109,  page  628,  and  the  menstrual  blood 
was  thus  turned  into  the  sinus  A  B,  and  escaped  by  the  bladder. 

In  one  case  the  opening  was  so  high  up  in  the  uterine  canal,  that 
I  deemed  it  unsafe  to  attempt  an  operation  for  reaching  the  sinus.  To 
prevent  pregnancy,  the  os  was  closed  in  one  of  the  women,  as  I  found 
the  pelvis  much  contracted,  and  learned  that  a  delivery  had  already 
been  so  difficult  as  to  greatly  endanger  her  life. 

Fig.  112  represents  a  condition  in  which  the  uterus  is  retro  verted 
and  bound  down  by  adhesions.  The  anterior  lip  has  sloughed  away, 
and  from  the  inflammation  extending  to  the  vesico-vaginal  septum  a 
fistula  has  been  formed  in  front  of  the  cervix. 

In  the  case  which  this  represents  extensive  cellulitis  also  occurred, 
followed  by  sloughing  in  the  cul-de-sac,  and  on  the  lateral  walls  of  the 
vagina.  As  a  consequence,  the  vagina  became  shortened,  and  the  vesico- 
vaginal septum  doubled  on  itself.  As  the  patient  lay  on  the  back  the 
finger  could  be  passed  into  the  bladder,  with  more  or  less  difficulty. 
But  the  parts  had  become  so  immovable,  from  the  inflammation  and 
contraction,  that  it  was  impossible  to  bring  the  fistula  into  view  except 
by  means  of  a  hand-glass  or  a  frontal  mirror,  and  a  small  laryngeal 
mirror.  Although  the  fistula  could  be  thus  seen  by  placing  the  small 
mirror  at  vl ,  it  was  impossible  to  make  use  of  the  reflected  light  for 
either  denuding  the  edges,  or  for  introducing  the  sutures.     The  fold 


634 


DIFFERE^S^T    FORMS    OF    FISTULA.' 


in  front  of  B  was  immovable,  but  I  attempted  to  overcome  tlie  diffi- 
culty bj  cutting  through  at  the  neck  of  the  bladder,  and  with  a  pair 
of  scissors  I  divided  the  septum  backward  in  the  median  line  to  the 
fistula.     But,  in  consequence  of  hemorrhage  and  of  the  prolapse  of 


Fig.  112. 


K 


Vesico-vaginal  fistula,,  with  loss  of  anterior  lip  of  cervix  (nte'-ns  retroverted). 

the  fundus  of  the  bladder  through  the  opening,  and  of  the  falling  of 
the  sides  together,  I  failed  in  every  position  and  with  every  instru- 
ment to  obtain  a  satisfactory  view. 

In  two  cases  in  which  I  cut  through  the  base  of  the  bladder,  after 
the  incision  had  healed,  I  closed  up  the  vaginal  canal  at  its  upper 
portion.  To  accomplish  this  I  freshened  as  much  of  the  canal  as 
could  be  brought  into  view  by  placing  the  patient  on  the  knees  and 
chest,  and  the  sutures  were  introduced  so  as  to  unite  the  sides  of  the 
canal  at  A  B.  This  left  the  uterine  canal  in  direct  communication 
with  the  bladder,  a  procedure  from  Avhich  no  harm  Avill  result  if  the 
canal  be  properly  closed;"  that  is,  in  such  a  manner  that  there  shall 
remain  no  receptacle,  or  a  pouch,  for  the  collection  of  stale  urine,  or 
a  sac  in  which  a  stone  could  form.  It  is  doubtless  an  acknowledg- 
ment of  defeat,  or  of  a  limit  to  our  resources,  when  such  a  procedure 
is  resorted  to;  yet,  sometimes  we  have  no  other  alternative.  We 
must,  however,  accept  as  a  principle  the  necessity  for  obliterating,  as 


VESICO-VAGINAL    FISTULA.  635 

far  as  possible,  any  cavity  in  which  the  urine  can  remain  and  become 
alkaline,  and  hence  phosphatic.  "Whenever  a  pouch  has  to  be  left, 
the  outlet  must  be  large,  and  so  formed  that  it  will  be  emptied 
thorougldy  whenever  the  bladder  is  evacuated.  Unless  this  is  care- 
fully observed  no  permanent  benefit  will  result  to  the  patient,  but,  on 
the  contrary,  the  raisjudgment  of  the  surgeon  will  lead  to  serious  con- 
sequences. Sometimes  the  bad  effects  may  be  delayed  if  the  patient 
can  be  made  to  realize  the  necessity  for  frequently  washing  out  the 
bladder  through  a  double  canula,  but,  even  with  this  care,  permanent 
exemption  from  trouble  is  not  to  be  expected. 

Whenever  urine  is  allowed  to  remain  a  long  time  in  the  bladder  it 
decomposes  and  becomes  phosphatic,  and  cystitis  invariably  results, 
leadiujj  to  oedema  of  the  submucous  tissues  and  obstruction  to  the 
mouths  of  the  ureters.  When  once  this  condition  becomes  established 
the  ureters  gradually  dilate,  and  it  then  remains  but  a  question  of 
time  before  disease  of  the  kidneys  develops,  with  death,  from  uraemia, 
as  the  consequence.  It  often  proves  a  fortunate  occurrence  for  the 
patient  when  an  encysted  stone  is  found.  This  either  cuts  through 
into  the  vagina  by  an  ulcerative  process,  thus  affording  the  needed 
relief,  or  so  much  irritation  ensues,  at  a  comparatively  early  stage, 
that  the  surgeon  is  compelled  to  interfere. 

There  exists  no  greater  malpractice  in  surgery  than  the  procedure 
which,  we  are  told,  was  practised  by  that  great  master,  the  late 
Prof.  Simon,  of  Heidelberg.  He  never  seemed  to  appreciate  the 
importance  of  the  principle  which  I  am  now  endeavoring  to  impress 
upon  the  reader.  Without  hesitation  he  would  shut  up  the  vagina 
when  difficulties  presented  themselves  in  bringing  together  the 
edges  of  a  fistula,  as  if  the  sole  object  was  to  give  a  retentive 
power  regardless  of  the  consequences.  From  my  own  observation 
I  have  learned  that  it  is  but  a  question  of  a  fcAV  months,  a  year, 
or  possibly  two,  before  serious  consequences  must  arise  after  leaving 
a  receptacle,  like  a  portion  of  the  vagina,  in  which  the  urine  may 
stagnate.  To  give  a  retentive  power  for  so  short  a  time  is  not  a 
sufficient  compensation  for  the  suffering  and  consequences  which 
supervene.  As  the  result  of  my  experience,  I  would  urge  that  the 
operation  should  never  be  resorted  to  under  any  circumstances.  The 
maximum  has  now  been  reduced  to  two  or  three  per  cent,  of  cases 
where  the  resources  of  the  surgeon  cannot  overcome  all  the  difficulties 
which  may  be  presented  in  closing  a  vesico-vaginal  fistula.  Something 
more  may  be  accomplished  in  the  future ;  but,  at  present,  these  in- 
curable cases  are  better  without  the  retentive  power  when  gained  by 


636  DIFFERENT    FORMS    OF    FISTULiE. 

Simon's  method.  The  surgeon  endeavors  to  cause  the  parts  to  heal 
thoroughly,  and  educate  the  patient  in  the  art  of  taking  care  of  her- 
self, and  in  this  way  much  can  be  done  to  render  her  condition  a 
comfortable  one. 

Whenever  the  destruction  of  tissues  has  been  so  extensive  as  to 
permit  the  inverted  bladder,  filled  with  intestines,  to  protrude  from 
the  labia  in  an  almost  strangulated  condition,  some  surgical  relief  is 
imperative.  In  such  cases  I  do  not  hesitate,  Avith  the  consent  of  the 
husband,  to  unite  the  sides  of  the  vagina  at  any  point  within  the  canal 
at  which  I  can  gain  the  needed  support  for  the  bladder.  This  is 
done  to  relieve  the  suffering  attendant  upon  the  prolapsed  bladder, 
and  it  is  very  effectual.  But  I  always  leave  an  opening  at  the  most 
dependent  portion,  and  one  above,  so  that  the  urine  cannot  accumu- 
late, and  the  parts  may  at  any  time  be  washed  out  if  necessary. 
After  the  surfaces  have  all  healed,  and  the  woman  has  learned  to 
keep  herself  free  from  excoriations,  her  health  will  remain  good,  and 
the  escape  of  urine  will  be  comparatively  but  a  slight  inconvenience. 
Certainly  no  comparison  can  be  drawn  between  the  comfort  of  one 
with  retentive  power  at  the  cost  of  cystitis  and  its  consequences,  and 
the  other  in  a  healthy  condition,  with  the  urine  escaping  into  a  cloth 
or  some  other  suitable  receptacle. 

3.  Losis  of  tissue  at  the  lower  portion  of  the  vagina,  extending  to 
one  ramus  or  to  both.  It  is  an  exception  to  the  rule  to  find  a  small 
fistula  in  close  contact  with  the  bone.  This  usually  happens  in  con- 
nection with  the  loss  of  a  large  portion  of  the  base  of  the  bladder,  by 
which  the  inner  face  of  one  or  both  rami  becomes  denuded,  so  that 
the  surface  of  the  bone,  covered  with  its  periosteum  only,  forms  a 
portion  of  the  fistulous  edge.  It  may  prove  an  easy  matter  to  free 
the  edges  of  a  large  fistula  so  that  they  can  be  brought  in  contact 
from  any  direction,  but  the  line  of  union  must  terminate  in  a  tri- 
angular opening,  the  base  of  Avhich  will  be  formed  by  the  ramus.  It 
then  becomes  impossible  to  close  such  an  opening  in  the  same  line, 
beyond  a  certain  point,  even  with  a  superabundance  of  tissue.  The 
usual  plan  is  to  unite  the  edges  of  the  fistula,  by  one  operation,  up  to 
the  ramus  as  close  as  can  be  done,  leaving  the  triangular  space  for  a 
subsequent  operation.  To  close  such  an  opening  against  the  inner 
face  of  the  ramus,  in  even  a  thin  subject,  where  it  can  only  be  brought 
in  view  with  difficulty,  is  one  of  the  severest  tests  of  the  surgeon's 
skill  in  manipulation.  But  from  the  fact  that  the  line  of  the  ramus 
separates  and  diverges  from  the  edge  of  the  fistula,  such  a  condition 
must  be  incurable. 


FISTULA    IN    THE    NECK    OF    THE    BLADDER.  637 

One  of  two  plans  may  be  followed  for  closing  an  opening  in  this 
situation.  A  flap  may  be  dissected  off  from  the  vagina  above  and 
brought  down  over  the  opening,  the  raucous  surface  of  the  flap  being 
turned  in  towards  the  bladder.  Or  the  tissues  may  be  dissected  from 
the  base,  and  as  they  recede  the  edges  of  the  fistula  will  become 
free,  and  a  sufficient  distance  be  gained  between  the  fistula  and  the 
ramus  to  allow  of  the  passage  of  sutures.  This  plan  is  the  one  best 
for  the  general  operator,  and  is  most  suitable  for  the  greater  number 
of  cases.  But  the  chief  danger  is  from  hemorrhage,  which  may  be 
severe  if  a  large  branch  of  the  subpubic  artery,  which  runs  along  the 
inner  edge  of  the  ramus,  be  wounded.  This  accident  can  be  avoided 
by  using  a  pair  of  scissors  to  free  the  tissues  from  their  close  union 
with  the  bone,  the  parts  at  the  same  time  being  kept  on  the  stretch 
by  the  traction  of  a  tenaculum.  When  it  is  necessary  to  make  an 
extensive  dissection  the  tissues  must  be  freed  with  the  handle  of  a 
scalpel,  as  the  inner  edge  of  the  ramus  is  approached.  The  line  of 
incision  ought  generally  to  be  greater  in  length  than  in  depth,  since, 
after  the  mucous  membrane  has  been  once  freely  divided,  the  elasticity 
of  the  subjacent  cellular  tissue  admits  of  great  mobility.  The  opera- 
tion can  seldom  be  performed  in  any  other  position  than  on  the  knees 
and  chest.  But,  under  all  circumstances,  it  is  exceedingly  difficult 
to  introduce  the  sutures.  From  the  close  proximity  of  the  bone,  but 
little  space  is  left  to  turn  the  needle,  and  a  number  are  generally 
broken  before  the  completion  of  the  operation.  By  introducing  two 
silk  loops,  from  within  outwards,  through  the  edges  of  the  fistula,  at 
opposite  points,  one  loop  can  be  passed  into  the  other  and  drawn 
through,  so  that  it  becomes  continuous,  as  if  only  a  single  one  had 
been  passed,  and  it  will  then  be  a  simple  matter  to  attach  the  wire 
and  draw  it  through  in  the  usual  manner. 

4.  Sloughing  or  laceration  at  the  neck  of  the  bladder.  The  most 
frequent  injury  to  the  neck  of  the  bladder  is  a  laceration,  the  conse- 
quence, in  all  probability,  of  traction  exerted  while  the  bladder  is 
over- distended  by  urine.  The  urethra  is  not  only  torn,  but  also  the 
neighboring  soft  parts,  so  that  a  rent  generally  extends  from  one 
ramus  to  the  other.  The  portion  of  the  urethra  close  up  to  the  neck  of 
the  bladder  soon  becomes  so  dilated  that  the  finger  may  be  introduced 
through  it  for  some  distance  w^ithin  the  canal.  The  mucous  membrane 
anterior  to  the  neck  of  the  bladder  protrudes  in  a  hypertrophied  mass 
resembling  a  prolapsed  anus.  In  the  centre  of  the  prolapse  the 
vesical  orifice  of  the  urethra  will  be  seen  undilated,  and  to  correspond 
in  diameter  to  the  portion  of  the  urethral  canal  in  the  anterior  flap. 


638  DIFFERENT    FORMS    OF    FISTULA. 

At  the  operation  for  closing  this  laceration,  it  is  always  difficult  to 
freshen  the  surfaces  in  consequence  of  the  prolapsed  mass  filling  up 
the  sulcus ;  this  may  be  easily  returned,  but  it  will  at  once  roll  out 
again.  The  parts  must  be  approximated  over  a  large  sized  sound, 
which  will  put  the  canal  somewhat  on  the  stretch,  and  this  will  also 
prove  the  best  means  for  keeping  back  the  prolapsed  tissues  while  the 
sutures  are  being  introduced.  To  secure  the  sutures  properly  on 
each  side  of  the  urethra  they  must  necessarily  approximate  to  a 
parallel  course  in  relation  to  each  other,  and  in  so  doing  the  excess 
of  tissue  would  be  rolled  into  the  bladder.  Notwithstanding  the 
dilated  outlet  becomes  folded  somewhat  on  itself  between  the  sutures 
which  embrace  the  diameter  of  the  urethra,  yet,  if  they  are  passed 
so  as  to  bring  the  edges  of  the  canal  at  each  point  into  exact  apposi- 
tion, the  catheter  Avill  meet  with  no  obstruction,  and  the  excess  of 
tissue  will  soon  retract. 

Along  with  the  greater  portion  of  the  vesico- vaginal  septum  or  base, 
the  neck  of  the  bladder  also  sloughs  away.  To  give  retentive  power 
to  these  cases,  the  neck  of  the  uterus  has  to  be  drawn  down  and 
united  to  the  neck  of  the  bladder.  By  this  procedure  the  uterus  be- 
comes retroverted,  and  the  previous  anterior  wall  is  then  made  to  form 
the  bottom,  or  base,  of  the  bladder.  An  excess  of  loose  tissue  at  the 
neck  of  the  bladder  gives  the  woman  retentive  power  in  the  absence 
of  a  sphincter  muscle.  This  tissue  is  generally  destroyed  extensively 
when  a  slough  takes  place  in  its  neighborhood,  and  then  the  retentive 
power  is  not  always  gained  by  closing  the  fistula.  When  the  loss  of 
tissue  has  been  extensive,  and  has  necessitated  the  drawing  down  of 
the  neck  of  the  uterus,  the  usual  effect  of  the  traction  then  exerted 
is  to  pull  the  remains  of  the  urethra  so  far  back  under  the  arch  of  the 
pubes  that  the  urine  escapes.  Sometimes  all  the  urine  flows  away 
from  the  urethra,  but  sometimes  it  will  only  escape  in  a  small  quantity, 
and  only  upon  sudden  effort  to  expel  it.  In  extreme  cases,  when  the 
stump  of  the  urethra  has  been  drawn  back,  the  passage  becomes  as 
direct  into  the  bladder  as  if  a  gimlet  hole  had  been  made  through  its 
base.  In  a  large  proportion  of  cases  the  retentive  power  may  be 
aided  by  utilizing  the  neck  of  the  uterus,  Avhile  sometimes  it  may  also 
be  necessary  to  lengthen  the  urethra,  as  will  be  described  hereafter. 

As  the-  urine  accumulates  the  bladder  rises  in  the  pelvis,  and  if 
we  can  so  unite  the  cervix-uteri  Avith  the  neck  of  the  bladder  that  it 
will  be  drawn  up  and  made  to  press  behind  the  pubes,  retentive  power 
will  be  secured.  The  urethra  is  to  be  united  to  the  cervix  just  in  front 
of  the  OS,  as  shown  in  Fig.  113,  the  effect  of  which  is  to  crowd  the 


URETHRAL    FISTULA. 


639 


anterior  lip  against  the  pubes  just  in  proportion  as  the  uterus  is  dragged 
upward.  In  many  cases  the  desire,  or  appreciation  of  the  necessity, 
to  empty  the  bladder,  is  never  regained  after  extensive  sloughing, 
notwithstanding  that  retentive  power  may  have  been  restored  by  art. 


Fis.  113. 


Cervix-uteri  united  to  neck  of  bladder  to  secure  retention. 


It  then  becomes  necessary  to  empty  the  bladder  at  regular  intervals, 
and  Avhile  many  are  able  to  do  so  by  the  action  of  the  abdominal 
muscles,  the  introduction  of  a  catheter  by  the  woman  herself  is  the 
safest  plan  to  pursue.  The  position  on  the  knees  and  elbows  is  the 
one  which  Avill  insure  the  emptying  of  the  urine  from  the  long  pouch 
behind  the  uterus,  and  in  proportion  to  the  difficulties  of  the  case, 
the  more  essential  will  be  the  necessity  for  washing  out  the  bladder 
from  time  to  time. 

5.  Injuries  to  the  urethra  and  defective  development.  Small 
openings  are  sometimes  found  in  the  course  of  the  urethra,  and  are 
generally  the  result  of  lacerations.  They  are  easily  closed  over  a 
large  sized  catheter,  and  the  line  of  union  should  be  in  the  long  axis 
of  the  canal,  that  the  formation  of  a  band  across  the  course  of  the 
urethra  may  be  prevented.  The  edges  of  the  fistula  are  generally  too 
thin  to  be  united  alone,  so  that  it  is  almost  always  necessary  to  freshen 


640  DIFFERENT    FORMS    OF    FISTULiE. 

a  portion  of  vaginal  tissue.  When  this  has  been  done,  it  is  always 
prudent,  even  if  not  essential,  to  relieve  the  traction  hy  making 
with  a  pair  of  scissors,  two  parallel  incisions  on  each  side  of  the 
urethra.  A  much  smaller  sized  wire  should  be  used  for  this  operation, 
and  the  greatest  care  must  be  exercised  in  securing  the  sutures,  so 
that  the  parts  to  be  united  will  be  just  brought  into  apposition  and 
not  more.  •  The  tissues  are  erectile  in  character,  and  with  the 
oedema  and  concomitant  swelling  of  the  parts,  the  sutures  are  liable 
to  cut  through,  even  with  all  due  care.  The  siitures  may  be  carried 
entirely  through  into  the  urethra,  when  it  is  advisable  to  do  so  owing  to 
the  scanty  amount  of  tissue.  And  it  will  do  no  harm,  provided  they 
do  not  cut  out  from  the  traction,  for  the  small  passage  occupied  by  the 
wire  will  soon  contract  and  disappear  after  it  has  been  removed. 
These  sutures  may  be  secured  by  twisting,  as  is  usually  done,  pro- 
vided they  are  properly  bent  flat  to  the  vaginal  surface,  where  they 
will  not  prove  a  source  of  irritation.  When  the  operator  is  sufficiently 
expert  to  judge  of  the  proper  point  at  which  in  tissue  of  this  character 
the  sutures  should  be  secured,  a  compressed  shot  will  prove  the  best 
means  for  the  purpose.  Through  a  hole  in  the  centre  of  a  duck  shot 
both  ends  of  the  wire  are  to  be  passed,  and  as  these  are  held  in  one 
hand,  the  shot  in  the  grasp  of  a  pair  of  forceps,  is  slid  down  to  the 
proper  point  and  then  compressed.  This  is  sufficient  to  secure  the 
ends  of  the  wire,  and  after  these  have  been  cut  off  close  to  the  shot, 
there  will  be  less  dragging  and  less  irritation.  This  was  the  plan 
adopted  by  Dr.  Sims  for  securing  the  sutures  in  his  early  operations, 
and  is  admirable  for  vascular  and  erectile  tissues,  since  by  it  we  can 
better  guard  against  strangulating  the  parts. 

I  have  succeeded  in  restoring  the  whole  urethra  by  plastic  surgery 
in  six  or  seven  cases,  but  only  partially  so  in  others.  The  operation 
may  be  regarded  as  one  of  the  curiosities  of  surgery,  requiring  an 
indefinite  time,  and  an  unlimited  degree  of  patience  for  its  completion. 
The  urethra  may  be  lengthened,  and  this  is  an  operation  to  be  fre- 
quently resorted  to.  But  to  construct  the  Avhole  urethra  should  never 
be  attempted  unless  the  patient  be  unusually  intelligent,  and  both  she 
and  the  surgeon  realize  fully  the  greatness  of  the  undertaking,  and 
all  of  its  possible  disappointments. 

I  have  had  the  results  of  the  labor  of  over  three  years  destroyed  in 
a  moment  by  a  woman,  who  attempted  the  silly  gymnastic  tricky  of 
letting  her  body  down  to  the  floor,  by  separating  her  legs  as  far  apart 
as  possible,  foolishly  wishing  to  demonstrate  that  she  was  cured  and 
expecting  an  early  discharge  from  the  hospital.     I  have  seen  the 


OPERATION  TO  SECURE  RETENTION  OF  URINE.     641 

whole  urethra  lost  hy  the  clumsy  use  of  a  catheter,  and  sometimes  the 
same  occurs  from  a  want  of  proper  vitality.  But  after  years  have 
been  thus  spent  in  opening  a  vagina,  and  in  bridging  over  a  fistula,  or 
in  forming  the  urethra,  a  more  common  fate  is  to  hear  that  all  has  been 
lost  in  a  few  weeks,  after  the  woman  returned  home  cured,  and  all 
from  neglect  in  emptying  or  washing  out  the  bladder  properly.  There- 
fore as  I  advance  in  life,  and  come  to  place  a  lower  estimate  upon  the 
amount  of  common  sense  developed  in  the  average  individual,  I  grow 
less  disposed  to  waste  my  energy  on  the  slim  chances  of  success  or 
permanent  benefit  from  this  procedure. 

Formerly  it  was  my  impression  that  there  could  be  no  retentive 
power,  when  the  neck  of  the  bladder  had  been  lost,  unless  the  new 
passage  was  made  to  enter  at  as  high  a  point  as  possible.  It  was 
thought,  as  I  have  already  stated,  that  as  the  urine  accumulated,  the 
bladder  must  rise  out  of  the  pelvis,  and  in  doing  so,  that  the  patulous 
passage  is  drawn  tight  under  the  arch  of  the  pubis,  thus  securing  a 
retentive  power  before  the  urine  had  reached  the  level  of  the  opening. 
It  was  customary  to  make  a  false  passage  into  the  bladder  through 
the  sub-pubic  ligament,  or  through  the  tissues  behind  the  pubes,  and 
when  this  tract  had  healed,  the  new  canal,  which  was  to  serve  as  an 
urethra,  was  then  joined  to  it. 

The  risk  from  retention  of  stale  urine  in  the  bladder,  was  of  course 
fully  appreciated,  and  that  this  could  only  be  avoided  when  it  was  pos- 
sible to  fully  impress  the  patient  with  the  necessity  of  washing  out  the 
bladder  daily.  The  result  of  my  subsequent  experience,  however,  led 
me  to  look  for  some  other  expedient  to  obviate  the  risk  which  trusting 
to  the  judgment  of  the  patient  involves. 

On  reflection,  it  occurred  to  me,  that  with  the  entrance  to  the  blad- 
der at  the  most  dependent  part,  but  with  the  canal  extended  upward 
in  advance  of  the  natural  point  of  outlet,  the  traction  of  the  cicatricial 
tissue  might  be  so  regulated  as  to  gain  a  controlling  power.  There- 
fore, I  made  a  new  canal,  somewhat  trumpet-shaped,  with  the  idea  that 
if  the  traction  proved  sufficient  to  excite  a  retentive  power,  when  the 
pressure  of  the  abdominal  muscles  was  exerted  for  expulsion,  the  first 
portion  of  urine  forced  into  the  funnel  extremity,  would  easily  open 
the  canal.  It  was  also  thought  that  the  stream,  being  once  started, 
would  be  continued  by  the  force  behind,  and  that  the  retentive  power 
which  had  increased  with  the  accumulation,  would  lessen  in  proportion 
as  the  bladder  emptied. 

The  incisions  were  made  to  diverge  from  without  inwards,  and  di- 
41 


642  DIFFERENT    FORMS    OF    FISTULA. 

rectly  downwards,  instead  of  passing  obliquely  behind  the  flaps.  For 
it  had  been  noted  that  when  the  flaps  were  dissected  up,  there  could 
be  but  little  lateral  traction  exerted  by  the  cicatricial  tissue  on  the 
diameter  of  the  canal,  as  it  was  all  lost  behind  and  under  the  arch  of 
the  pubis.  By  separating  the  lines  of  incision,  the  lateral  force  ex- 
erted was  greatest  towards  the  outlet,  and  sufficient  in  the  beginning  to 
arrest  the  escape  of  urine,  unless  forced  open  with  a  stream  by  pres- 
sure of  the  abdominal  muscles. 

With  the  accumulation,  an  increasing  retentive  power  becomes  es- 
tablished along  the  whole  canal,  in  its  axis,  but  which  at  the  same 
time  can  be  readily  overcome  at  will.  In  other  words,  by  obtaining 
the  greatest  amount  of  traction  Avhich  can  be  exerted  by  the  cicatri- 
cial tissue,  the  triangular  surface,  between  the  two  incisions,  is  drawn 
tense,  with  the  efiect  of  flattening  together  the  two  sides  of  the 
canal  beneath.  Then,  in  addition,  with  the  base  of  the  triangle  to- 
wards the  bladder,  any  force  exerted  in  that  direction  would  be  uni- 
form along  the  whole  length  of  the  canal,  and  must  increase  with  the 
traction. 

The  congenital  defects  of  development  are  a  patulous  condition  of 
the  canal  and  a  cleft  urethra,  resembling  a  harelip.  The  first  condi- 
tion, when  found,  is  an  accompaniment  of  the  congenital  absence  of 
the  uterus  and  vagina,  and  has  been  already  referred  to  while  treating 
of  that  subject.  The  cleft  urethra  also  resembles  the  defect  found  in 
the  anus  and  extending  through  the  perineum,  which,  under  these 
circumstances,  is  absent ;  this  has  also  been  treated  of.  I  have  never 
operated  to  remedy  this  defect  in  the  urethra,  but  expect  to  do  so  at 
no  distant  day  for  a  young  woman  eighteen  years  of  age,  who  has 
never  had  a  perfect  retentive  power  of  urine  since  her  birth.  The 
appearance  closely  resembles  the  condition  left  after  the  meatus  has 
been  lacerated  in  dilating  the  urethra.  The  operation  which  would 
be  applicable  is  similar  to  the  one  employed  for  repairing  a  lacera- 
tion, and  will  be  treated  of  hereafter  when  describing  that  injury. 

6.  The  ureter  opening  into  the  vagina,  as  the  result  of  injury,  or 
as  a  congenital  defect.  The  ureter  can  scarcely  communicate  directly 
with  the  vagina  as  a  result  of  childbirth,  but  when  the  loss  of  tissue 
has  been  very  extensive,  so  as  to  involve  the  ureter  in  the  edge  of  the 
fistula,  it- becomes  sometimes  rolled  out  on  to  the  vaginal  Avail  in  the 
process  of  healing. 

It  is  not  a  rare  condition  to  find  the  urine  escaping  from  the  ureter 
into  the  cul-de-sac,  a  little  posterior  to  the  cervix,  but  the  lesion  is 
always,  in  my  opinion,  connected  Avith  an  attack  of  cellulitis.     In  the 


FISTULA    INVOLVING    A    URETER.  G43 

normal  condition  the  point  of  entrance  for  the  ureters  in  the  ba?e  of 
the  bhidder  is  at  least  an  inch  below  the  level,  and  about  the  same 
distance  in  front,  of  the  usual  opening  into  the  vagina.  In  fact  the 
ureters  have  no  direct  connection  with  the  sides  of  the  vagina,  but 
only  indirectly  through  the  connective  tissue  of  the  pelvis.  It  seems 
not  only  necessary  that  a  cellulitis  should  have  previously  existed, 
but  that  it  should  Jiave  terminated  in  a  pelvic  abscess  to  bring  about 
this  condition.  By  means  of  the  abscess,  the  ureter  is  dragged  up  to 
the  level  of  the  vagina  at  this  point,  Avhere  it  becomes  attached  by 
adhesive  inflammation.  As  the  course  of  the  ureter  must  then  be 
more  or  less  bent  at  an  angle,  the  passage  of  urine  to  the  bladder 
becomes  partially  obstructed.  This  condition,  in  time,  will  excite 
inflammation,  and  lead  to  an  opening  in  the  vaginal  wall  through 
which  the  urine  will  escape  from  the  ureter.  Whenever  this  accident 
has  followed  childbirth,  I  am  satisfied  that  the  explanation  offered  as 
to  its  connection  with  cellulitis  will  be  found  correct. 

Many  years  ago  a  case  came  under  my  observation  where  a  pelvic 
abscess  had  made  its  way  through  into  the  cul-de-sac  of  the  vagina, 
and  afterward  all  the  urine  of  one  kidney  apparently  escaped  by  this 
route.  I  was  then  unable  to  attempt  any  procedure  for  relief,  and 
have  never  known  the  result  in  the  case.  Since  that  time  I  have 
seen  two  instances  where  the  ureter  had  been  cut  across  in  the  same 
neighborhood  by  the  surgeon,  when  attempting  to  evacuate  into  the 
vagina  the  contents  of  a  pelvic  abscess.  When  the  abscess  is  between 
the  folds  of  the  broad  ligament  this  point  would  be  naturally  chosen 
for  its  evacuation,  on  account  of  its  dependent  position,  and  because 
fluctuation  would  always  be  most  marked  there.  This  not  being  the 
natural  position  for  the  ureter,  and  it  being  difficult  to  determine  with 
accuracy  if  it  is  thus  abnormally  located,  it  is  scarcely  possible 
to  guard  against  the  accident  in  using  a  bistoury.  As  rare  as- the 
accident  must  necessarily  be,  even  this  risk  may  be  lessened  some- 
what by  partially  emptying  the  abscess  by  means  of  an  aspirator. 
Afterwards  a  larger  opening  can  be  made,  and  the  distension  having 
been  relieved  this  would  allow  the  ureter  to  sink  below  the  level  of 
the  vagina.  Of  course,  if  adhesions  have  formed  between  the  ureter 
and  the  sides  of  the  vagina,  the  accident  cannot  be  guarded  against. 

For  the  relief  of  one  of  these  cases  I  closed  the  opening  into  the 
vagina,  hoping  that  the  urine  would  then  find  its  way  into  the  bladder. 
But  the  operation  failed,  for  after  an  hour  or  two  the  urine  forced  its 
way  between  the  sutures.  The  woman  died  suddenly  about  six  months 
afterwards,  and  I  made  a  post-mortem  examination.     It  was  found 


644  DIFFERENT    FORMS    OF    FISTULA. 

that  both  kidneys  were  in  an  advanced  stage  of  Bright's  disease,  the 
result  of  the  obstruction  to  the  ureters  hf  an  old  cellulitis.  The  ureter, 
on  which  I  had  operated,  Avas  adherent  to  the  side  of  the  vagina,  as 
I  have  described.  Its  passage  to  the  bladder  beyond  was  closed, 
while  the  canal  itself  was  enormously  dilated  as  far  up  as  the  kidney. 
The  history  of  the  other  case  is  as  follows : — 

Case  XLVI. — Mrs.  B.,  aged  25,  married  at  21 ;  sterile.  As  the 
result  of  a  fall,  had  been  an  invalid  for  two  years  and  a  half  previous 
to  being  admitted  to  the  Woman's  Hospital,  in  the  service  of  one  of 
my  colleagues.  She  had  had  a  pelvic  abscess  opened  at  home  some 
months  previous,  since  when  there  was  a  continuous  discharge  of  pus, 
and  the  urine  had  escaped  freely  by  the  vagina.  The  urine,  however, 
did  not  all  escape  by  the  vagina,  for  she  was  obliged  at  certain  inter- 
vals to  evacuate  the  bladder  in  the  usual  manner.  Shortly  after  her 
admission  an  attempt  was  made  to  enlarge  the  opening  between  the 
abscess  and  vagina,  but  the  hemorrhage  was  so  great  before  the  ope- 
ration was  completed,  that  the  cavity  had  to  be  filled  with  "iron 
cotton."  This  was  followed  by  a  fresh  attack  of  cellulitis  and  symp- 
toms of  blood-poisoning,  and  by  some  bleeding,  before  the  cotton 
could  be  removed,  or  before  it  became  loosened  by  suppuration. 
Shortly  afterwards  she  was  transferred  to  my  service.  Her  condition 
then  was  one  of  extreme  hectic,  with  high  temperature,  rapid  pulse, 
and  night  sweats.  At  least  half  a  pint  of  pus  was  being  discharged 
daily  from  the  abscess  through  the  rectum  and  vagina,  and  the  cavity 
of  the  abscess  was  filled  Avith  a  sabulous  deposit  from  the  foul  phos- 
phatic  urine.  After  some  three  weeks  her  condition  began  to  im- 
prove, as  the  chief  source  of  irritation  from  the  deposit  was  gradually 
removed,  and  the  raw  surfaces  healed.  At  first  an  hour  or  more  had 
been  devoted  every  day  to  picking  off  this  deposit  with  forceps,  or  to 
injecting  a  stream  of  hot  water  into  the  cavity  to  wash  it  away. 

I  now  advised  her  to  return  home  to  a  milder  climate,  and  there  to 
expose  her  body,  for  several  hours  a  day,  to  the  direct  action  of  the 
sun.  She  was  advised  to  diminish  gradually  the  quantity  of  morphine 
to  "which  she  had  become  accustomed,  to  take  from  fifteen  to  twenty 
grains  of  quinine  a  day,  and,  after  a  certain  time,  to  begin  the  use 
of  cod-liver  oil.  The  hot-water  injections  were  to  be  continued  night 
and  morning,  being  thrown  directly  into  the  cavity.  The  sea-voyage 
home  was  of  benefit,  and  she  began  to  improve  rapidly. 

A  year  afterwards  she  visited  New  York,  her  general  health  being 
entirely  restored,  and  entered  my  private  hospital  for  the  purpose  of 
having  something  done  to  control  the  escape  of  urine.  There  was  no 
longer  any  pus  passeil  from  either  the  vagina  or  rectum,  and  this 
change  had  been  brought  about  so  gradually  that  she  could  not  say 
when  it  had  occurred. 

I  was  not  confident  of  success  in  closing  the  opening  from  the  ureter 
into  the  vagina.  Until  the  exact  condition  of  the  canal  between  the 
seat  of  its  division  and  its  entrance  into  the  bladder  could  be  ascer- 


CASE    OF    FISTULA    OF    THE    URETER.  645 

tained,  I  Avas  unwilling  to  undertake  any  operation.  After  a  while 
it  was  found  that  wlien  some  indigo-water  was  injected  into  the  empty 
bladder,  the  urine  passed  by  the  vagina  remained  clear  for  a  certain 
time,  but  afterwards  it  would  suchlcnly  become  colored  and  increased 
to  about  double  the  (quantity.  It  was  thus  made  evident  that  all  the 
urine  of  one  kidney  escaped  into  the  vagina  without  entering  the 
bladder,  but  after  a  certain  time  the  bladder  would  become  filled  to 
some  point  of  overflow,  by  the  urine  from  the  other  kidney,  and  dis- 
charge into  the  vagina  through  a  common  opening.  A  probe  could 
be  passed  six  or  eight  inches  backward  and  upward  along  the  tract 
of  the  urethra,  as  it  w^as  supposed,  and,  with  some  difficulty,  off  to 
the  left  for  the  distance  of  an  inch ;  but  to  pass  it  into  the  bladder 
was  impossible.  After  a  number  of  careful  examinations  I  ascertained 
the  above  facts,  but  no  indication  as  to  the  actual  condition  in  the 
bladder.  I  determined  to  dilate  the  urethra  in  order  to  examine  the 
bladder,  by  the  aid  of  a  cylindrical  speculum  which  I  had  constructed 
for  tlie  purpose.  Dr.  George  T.  Harrison  and  Dr.  Bache  Emmet  as- 
sisted me  in  this,  and  ether  was  administered.  The  urethra  was 
dilated  as  recommended  by  Simon,  and  with  the  same  form  of  instru- 
ment used  by  him,  and  the  greatest  care  Avas  taken  to  employ  no 
violence.  The  canal  Avas  opened  Avithout  difficulty,  but  I  was  after- 
Avards  unable  to  obtain  a  view  of  the  interior  of  the  bladder  or  of  the 
mouths  of  the  ureters,  as  I  had  hoped  to  do.  I  Avas  greatly  disap- 
pointed to  find  that  the  incontinence  of  urine  continued  for  more  than 
twenty-four  hours,  by  Avhich  time  the  retentive  power  is  usually  fully 
regained.  I  realized  that,  in  spite  of  all  ray  care,  laceration  had 
occurred  at  the  neck  of  the  bladder,  so  that  every  drop  of  urine 
escaped,  and  I  was  apprehensive  that  the  incontinence  Avould  continue. 
I  delayed  making  any  further  examination  for  nearly  a  month,  hoping 
that  there  might  be  some  improvement,  but  this  did  not  take  place, 
and  the  patient's  condition  Avas  evidently  beyond  artificial  relief.  Up 
to  this  time  the  urethra  had  remained  sufficiently  open  for  me  to 
introduce  my  little  finger  into  the  bladder,  only  a  slight  effi3rt  being 
required  to  pass  the  meatus  Having  seen,  Avithin  a  recent  period, 
the  same  condition  result,  in  several  cases,  from  dilating  the  urethra, 
I  determined  to  open  the  bladder  with  the  vicAv  of  investigating  this 
injury,  and  to  ascertain  how  far  the  divided  ureter  was  pervious. 
This  was  done  November  6,  1875,  when  I  Avas  again  assisted  by  Drs. 
Harrison  and  Emmet.  After  she  had  been  fully  etherized  she  Avas 
placed  on  the  left  side,  Sims's  speculum  introduced,  and  I  entered  the 
bladder  by  the  method  described  for  making  an  artificial  fistula  for 
the  relief  of  cystitis.  The  incision  Avas  continued  Avith  a  pair  of  scis- 
sors as  close  up  to  the  uterus  as  Avas  deemed  safe,  and  then  forward 
to  the  neck  of  the  bladder,  laying  open  the  urethra  in  a  continuous 
line  for  half  of  its  length,  Avithout  cutting  entirely  through  at  the  neck 
of  the  bladder.  Through  this  long  incision  a  large  size  duck-bill 
speculum  Avas  passed  under  the  ai'ch  of  the  pubis  into  the  bladder. 
Sufficient  light  Avas  obtained  to  illuminate  every  portion  of  the  bladder 
except  the  part  covered  hj  the  speculum.     With  a  tenaculum  I  rolled 


646  DIFFERENT    FORMS    OF    FISTULA. 

out  the  flaps,  one  after  another,  on  each  side,  and  exposed  the  mouths 
of  the  ureters  -without  difficulty.  The  probe  passed  along  the  course 
of  the  right  ureter  for  a  distance  sufficient  to  show  that  it  was  in  a 
normal  condition.  On  the  other  side  it  could  not  be  advanced  to  a 
greater  distance  than  an  inch,  when  a  solid  septum  was  felt  between 
that  point  and  the  opening  into  the  vagina.  By  introducing  another 
sound  in  the  other  part  of  the  ureter,  towards  the  kidney,  it  was  evi- 
dent that  the  course  of  the  two  portions  of  the  canal  were  not  in  the 
same  direction.  It  was  also  shown  that  a  sharp  turn,  or  angle,  ex- 
isted between  the  two  points,  so  that  if  an  attempt  was  successful  in 
forcing  a  passage  from  the  bladder,  either  perforation  would  occur  or 
the  adhesions  would  be  separated  from  the  vagina,  and  the  urine 
would  escape  into  the  peritoneal  cavity. 

After  some  difficulty  I  succeeded  in  finding  the  opening  where  the 
abscess  had  emptied  into  the  bladder.  It  was  situated  to  the  left  and 
just  below  the  peritoneum,  where  this  dips  down  between  the  broad 
ligament  and  side  of  the  bladder.  By  inserting  my  finger  into  the 
bladder  I  was  able  to  advance  a  probe  from  the  vagina  along  the  tract 
of  the  old  abscess  until  it  passed  into  the  bladder  through  the  opening 
I  have  described  above.  I  also  ascertained  by  this  examination  that 
the  portion  of  the  urethra  entering  the  bladder  was  permanently 
closed,  and  that  nothing  remained  of  the  old  pelvic  abscess  but  the 
tract  which  had  been  kept  open  by  the  overflow  of  urine  from  the 
bladder.  As  I  passed  the  light  silver  probe  from  the  bladder  along 
this  tract  into  the  ureter,  I  could  feel  it  by  means  of  a  sound  intro- 
duced through  the  vaginal  opening.  This  satisfied  me  fully  that  I 
could  with  safety  close  the  opening  into  the  vagina  and  turn  the  urine 
into  the  bladder  from  the  left  kidney  through  the  tract  of  the  old 
abscess. 

I  had  opened  a  portion  of  the  urethra  and  had  partially  cut  through 
the  tissues,  at  the  entrance  of  the  urethra  into  the  bladder,  for  the 
purpose  of  being  able  to  roll  out  the  parts  at  the  neck  and  bring  the 
lacerated  portion  into  view.  I  saw  distinctly  how  this  fissure  left  a 
crack  so  that  the  parts  could  not  fold  together  properly  and  re-estab- 
lish the  retentive  power.  I  introduced  the  sutures  into  the  edges  of 
the  divided  urethra  from  the  nearest  angle  of  the  wound  in  the  usual 
manner  and  over  a  large-sized  block-tin  catheter  tube.  The  sides  of 
the  laceration  I  carefully  freshened,  and  passed  a  suture  so  as  to  bring 
together  the  edges  along  the  mucous  membrane,  and  then  to  the  oppo- 
site side  through  the  little  strip  of  tissue  which  had  been  left  undi- 
vided. When  this  suture  was  twisted,  it  simply  brought  the  sides  of 
the  laceration  together  Ayith  the  divided  tissues  over  the  neck  of  the 
bladder  without  in  any  manner  encroaching  upon  the  capacity  of  the 
urethra.  ■  The  remaining  portion  of  the  vesico-vaginal  septum  was 
left  open  for  the  free  escape  of  urine,  and  to  render  the  use  of  the 
catheter  unnecessary  until  the  parts  just  united  had  regained  their 
natural  condition.  Tlie  operation  was  successful,  and  the  sutures 
were  removed  on  the  eighth  day 

Dec.  5.    (The  same  gentlemen  assisting  me.)     Ether  was  given,  and 


FISTULA    OF    THE    URETER.  647 

T  closed  the  artificial  vesico-vairinal  fistula  and  the  opening  from  the 
ureter.  The  patient  was  placed  in  bed,  and  in  every  respect  tiie  case 
was  treated  as  after  the  operation  for  fistula.  At  the  end  of  six 
weeks  she  returned  home  perfectly  well,  and  retaining  at  will  every 
drop  of  urine.  Several  months  after  her  return  she  liad  a  fall  down 
a  flight  of  stairs,  and  wrote  to  me  in  great  alarm  that  she  was  suft'er- 
ing  from  incontinence  of  urine  as  a  consei^uence.  But  before  she 
received  my  letter,  advising  her  return  to  me,  she  had  already  re- 
gained the  control,  and  has  continued  well,  as  I  have  been  informed 
within  a  few  months. 

The  result  in  this  case  is  unique,  and  while  it  may  be  seldom  that 
the  same  procedure  could  be  adopted  with  safety,  several  important 
and  practical  lessons  are  to  be  drawn  from  it.  There  are  many  con- 
ditions of  the  bladder  where  it  would  be  good  practice  to  lay  open  the 
septum  freely,  as  was  done  in  this  case,  and  by  means  of  the  two 
instruments  form  a  clear  diagnosis  and  apply  the  necessary  treatment. 
No  other  single  fact  is  more  clearly  established  than  that  such  an  in- 
cision will  rapidly  close  up,  or  at  least  to  a  small  opening,  if  the  edges 
are  kept  clean,  and  the  case  properly  managed.  Should  there  be  no 
special  indication  for  keeping  the  incision  open,  the  sutui*es  can  be 
introduced,  and  the  whole  line  readily  closed  immediately  after  making 
the  examination.  I,  however,  do  not  advocate  this  procedure  in  pri- 
vate practice,  when  it  is  always  difficult  to  secure  to  the  patient 
the  proper  after-treatment.  The  operation  can  never  be  a  simple  or 
promising  one  except  under  the  most  favorable  circumstances. 

Before  entering  the  bladder,  in  the  case  I  have  last  cited,  I  had 
determined  to  close  the  opening  from  the  old  abscess  if  the  ureter 
were  found  pervious.  In  this  case  there  was  no  occasion  for  doing 
so,  as  the  canal  had  to  be  used  for  the  passage  of  the  urine  into  the 
bladder.  But  I  saw  that  it  was  feasible  to  close  such  an  opening 
within  the  bladder,  as  readily  as  if  situated  in  the  upper  portion  of 
the  vagina.  The  cases  are  not  rare  where,  after  a  pelvic  abscess, 
feces  and  flatus  have  continued  to  pass  into  the  bladder,  or  urine  into 
the  vagina  or  rectum,  long  after  the  original  condition  has  disappeared. 
I  am  now  satisfied  that  the  bladder  end  of  an  opening  in  these  cases 
can  be  closed  Avithin  that  cavity  and  with  safety,  since  there  must 
always  be  the  remains  of  thickened  tissue  behind  it  to  receive  the 
suture.  I  am,  moreover,  the  more  confident,  from  my  knowledge  of 
the  fact  that  women,  in  comparison  with  men,  bear  such  operations 
well.  It  is  a  provision  of  nature  that  the  female  bladder  is  very 
tolerant  to  injury,  or  the  dangers  of  parturition  would  be  far  greater. 
There  is  no  comparison  between  the  sexes  as  to  this  degree  of  tole- 


648  DIFFERENT  FOKMS  OF  FISTULA. 

ranee  ;  a  man  ^vould  lose  his  life  were  he  subjected  to  procedures  or 
injuries  that  cause  little  irritation  in  a  woman. 

Congenital  defects  in  the  position  of  the  mouth  of  the  ureters  are 
very  rare.  I  have  seen  but  one  case  in  which  the  opening  of  the 
ureter  into  the  vagina  existed  from  birth.  Dr.  AVilliam  H.  Baker,  of 
Boston,  a  former  house  surgeon  in  the  Woman's  Hospital,  has  cured 
such  a  case,  where  the  ureter  came  out  near  the  meatus  of  the 
urethra.  At  mj  suggestion  he  dissected  up  a  portion  of  the  end  of 
this  ureter,  made  an  opening  under  its  course,  near  the  neck  of  the 
bladder,  then  turned  the  stump  down  mto  the  opening,  and  closed  the 
vaginal  surface  over  it.  The  result  was  a  success,  and  there  is  no 
similar  case,  to  my  knowledge,  on  record. 

I  contemplated  a  somewhat  like  procedure  in  my  case  for  leading 
the  urine  into  the  bladder.  As  the  mouth  of  the  ureter  presented 
just  on  a  line  with  the  os  uteri,  I  could  not,  of  course,  dissect  up  any 
portion  of  the  canal,  nor  could  I  have  entered  the  bladder  at  this 
point  with  safety.  I,  therefore,  determined  to  make  a  canal  along 
the  vaginal  surface  until  I  reached  the  base  of  the  bladder,  where 
the  septum  was  thinnest  and  the  two  cavities  in  the  closest  relation. 
Then  I  intended  to  remove  a  small  portion  from  the  septum,  just  in 
front  of  where  the  false  passage  terminated,  and,  after  the  sides  of 
this  had  healed,  to  cover  the  vaginal  end  with  a  flap  dissected  up  and 
turned  for  the  purpose.  I  succeeded  in  forming  a  canal,  as  a  new 
urethra  would  be  made,  by  turning  over  together  the  vaginal  tissue, 
and  it  extended  from  the  mouth  of  the  ureter  to  the  point  at  which  I 
intended  to  enter  the  bladder.  At  this  stage,  during  a  temporary 
visit  home  for  a  few  months,  the  patient  died  from  an  attack  of  pneu- 
monia ;  at  least  I  judged  it  to  be  pneumonia  from  the  statement  of 
her  friends. 

7.  Openings  into  the  rectum  from  the  vagina.  For  all  practical 
purposes  we  might  confine  the  consideration  of  this  special  injury  to 
the  effects  of  childbirth.  T  will,  however,  briefly  refer  to  other  cases, 
such  as  cancerous  ulceration  and  syphilitic  abscess.  AVhen  cancer 
has  advanced  so  far  as  to  involve  the  bladder  or  rectum,  nothing  can 
be  done  to  repair  the  injury.  There  remains  no  course  of  treatment 
beyond  close  attention  and  cleanliness,  and  an  eff'ort  to  make  the 
patient  as -comfortaVjle  as  possible. 

We  meet  with  cases  of  recto-vaginal  fistula  where,  at  first  sight,  it 
is  difficult  to  determine  the  cause.  The  difficulty  will  be  all  the 
greater  should  the  patient  have  had  syphilis,  as  she  would  probably 
be  anxious  to  conceal  the  fact. 


RECTO-VAGINAL    FISTULA.  G49 

The  coexistence  of  syphilis  with  the  injury  is  a  most  important 
matter  for  the  surgeon  to  determine,  since  no  benefit  can  be  expected 
from  any  procedure  of  a  plastic  character,  about  the  vagina,  when 
the  parts  have  been  destroyed  by  syphilitic  sloughing.  Generally, 
sloughing  first  takes  place  about  the  urethra  or  neck  of  the  bladder, 
and  the  rectal  difficulty  occurs  later,  being  produced  by  the  discharge 
finding  its  way  into  the  anus,  where  it  excites  inflammation  which 
results  in  the  formation  of  abscess  between  the  rectal  and  vaginal 
walls.  The  abscess  opens  into  the  vagina,  generally  just  behind  the 
sphincter  ani  muscle,  the  opening  into  the  rectum  being  usually 
obli([ue  and  complicated  by  stricture,  to  a  greater  or  less  degree,  in 
front  of  it. 

So  far  as  my  observation  has  extended,  I  may  state  that  the 
presence  of  a  stricture  just  within  the  anus  is  always  a  probable 
evidence,  if  not  positive  proof,  that  the  lesion  is  the  result  of  syphilis. 
Cancer  may  extend  from  above  and  produce  a  stricture  at  the  same 
point,  but  when  this  occurs  there  can  be  no  room  for  doubt  that  the 
disease  is  cancer,  and  the  stricture  will  be  found  to  involve  the  whole 
rectum. 

When  a  recto- vaginal  fistula  is  situated  directly  against  the  sphincter 
it  is  always  difficult  to  obtain  good  union,  in  consequence  of  constant 
contractions  of  the  muscle.  In  such  a  case  it  is  necessary  to  divide 
the  perineum  and  sphincter  directly  through  to  the  fistula  with  a  pair 
of  scissors.  The  sides  of  the  fistula  should  be  freshened,  and  the 
case  treated  as  if  a  laceration  through  the  perineum  had  occurred, 
this  being  the  only  plan  by  which  we  can  be  certain  that  the  edges 
have  been  thoroughly  denuded.  Should  the  operation  partially  fail, 
a  second  one  would  be  successful.  But  if  the  parts  be  thus  divided 
through  tissues  Avhich  have  undergone  more  or  less  syphilitic  slough- 
ing, the  condition  of  the  patient  will  have  been  rendered  infinitely 
worse;  I  have  never  succeeded  in  obtaining  union  in  the  sphincter 
and  perineum  of  such  a  case. 

I  would  recommend  a  thorough  course  of  constitutional  treatment 
before  any  operation  is  attempted,  and  that  the  stricture  be  first  re- 
moved before  an  effiDrt  is  made  to  close  the  fistula  by  any  method  ;  other- 
wise, its  situation  will  force  the  flatus  in  the  direction  of  the  fistula,  if  it 
shall  have  been  closed,  and  cause  it  to  find  exit  between  the  sutures. 

To  close  a  recto-vaginal  fistula,  from  the  vaginal  side,  is  always 
more  difficult  than  it  is  for  one  opening  into  the  bladder.  The  diffi- 
culty arises  from  the  limited  means  we  have  at  command  for  bringing 
the  parts  into  view  without  dragging  them  down. 


650  DIFFERENT  FORMS  OF  FISTULA. 

For  an  examination,  it  is  necessary  to  have  the  patient  on  the  back 
with  the  legs  flexed  over  the  abdomen,  and  to  employ  Sims's  speculum 
placed  under  the  arch  of  the  pubes,  and  a  tractor  held  on  each  side 
by  an  assistant,  if  necessary,  to  bring  the  parts  into  view.  If  the 
patient  be  anaesthetized,  the  sphincter  can  be  moderately  stretched, 
before  placing  the  woman  on  the  left  side,  then  with  a  speculum  in 
the  rectum,  the  fistula  can  be  readily  brought  into  view.  Before 
making  such  an  examination  it  is  always  best  to  wash  out  the  rectum 
by  an  enema,  and  it  Avill  add  greatly  to  the  comfort  of  the  operation 
to  have  a  large  dressing  sponge,  with  a  string  attached  to  it  placed 
well  up  at  the  sigmoid  flexure. 

A  recto-vaginal  opening  is  generally  much  larger  on  its  vaginal  than 
on  its  rectal  aspect.  Its  edges  are  beveled,  and  as  a  rule  are  more 
difficult  to  be  brought  into  apposition.  Consequently,  freeing  the 
edges  is  a  more  essential  feature  of  the  preparatory  treatment  than  it 
is  with  a  vesico- vaginal  fistula.  Whenever  the  edges  of  a  rectal  fis- 
tula can  be  brought  together,  the  subsequent  steps  of  the  operation  are 
essentially  the  same  as  for  vesico-vaginal  fistula,  and  the  extent  to 
which  the  tissues  are  to  be  divided  is  to  be  estimated  in  the  same 
manner,  by  tentative  traction  with  the  tenaculum. 

Cases  are  met  with  occasionalh^  when  no  extent  of  division  of  tissue 
on  the  vaginal  surface  will  permit  of  the  edges  being  brought  together. 

If  traction  is  tried  in  such  a  case  it  will  be  at  once  demonstrated 
that  the  parts  are  no  longer  drawn  up  into  folds,  but  that  the  vaginal 
and  rectal  walls  are  firmly  adherent.  In  such  a  case  it  is  necessary 
to  split  the  edges  of  the  fistula  on  each  side  to  a  depth  sufficient  to 
permit  the  edges  of  the  rectal  wall  to  be  brought  together  below, 
leaving  the  vaginal  opening  to  be  filled  up  by  granulations.  Nar- 
rowing of  the  rectum  would  seem  to  be  an  inevitable  consequence  of 
this  method,  but  the  rectal  tissues  are  so  elastic  that  no  appreciable 
constriction  follows  this  procedure. 

On  May  28,  1870,  I  closed  a  recto-urethral  fistula  in  a  gentleman 
from  Kentucky,  at  the  request  of  the  late  Dr.  J.  C.  Xott.  The  case 
was  reported'  but  without  giving  the  method  in  detail,  and  I  now  give 
it  in  full,  as  it  seems  well  to  illustrate  the  manner  of  closing  from  the 
rectum  similar  openings  in  the  female  organs. 

"  On  thelst  of  December,  1868,  a  large  stone  of  irregular  shape, 
weighing  five  ounces,  was  removed  by  the  lateral  operation,  which 
left  a  fistulous  opening  in  the  rectum,  through  Avhich  the  urine  passed." 
"A  portion  of  the  urine  continued  to  discharge  by  the  rectum  up  to 

>  Case  of  Recto-urethral  Fistula,  by  J.  C.  Nott,  M.D.;  N.Y.  Med.  Journ.,  Sept.  1870. 


CASE    OF    RECTO-TJRETIIRAL    FISTULA    IN    A    MAN.         651 

the  time  of  his  arrival  in  New  York,  and  no  attempt  had  been  made 
to  close  the  opening.  Not  only  did  a  portion  of  the  urine  pass  through 
the  rectum,  but  fecal  matter  and  gas  frequently  escaped  with  the  urine 
through  the  urethra.  The  feces  sometimes  formed  an  annoying  tem- 
porary obstruction  to  the  passage  of  the  urine  through  the  penis. 
The  bladder  was  irritable,  requiring  the  urine  to  be  passed  off  more 
frequently  than  natural.  The  rectum  was  also  irritable,  but  less  so 
than  is  usual  in  urinary  fistulte  opening  into  it."  I  had  no  opportu- 
nity of  examining  the  case  until  called  upon  to  operate.  When  the 
parts  were  brought  into  vieAV  by  placing  my  self-retaining  speculum 
in  the  rectum,  tAvo  oval  openings  were  seen  about  an  inch  apart,  one 
leading  into  the  bladder  and  the  other  to  the  urethra. 

Between  these  openings  a  narroAV  strip  of  urethral  mucous  mem- 
brane could  be  traced,  which  represented  all  that  remained  of  the 
membranous  portion  of  the  urethra.  The  appearance  was  as  if  a 
section  had  been  removed,  such  as  would  be  presented  by  a  large  quill 
from  which  a  segment  had  been  removed  by  a  sharp  knife,  so  as  to 
leave  a  small  narrow  portion  in  the  centre.  The  facility  with  which 
I  succeeded  in  closing  this  opening,  by  supplying  the  loss  from  rectal 
tissue,  led  me  subsequently  to  employ  the  same  method  for  closing 
certain  cases  of  recto-vaginal  fistula.  The  rectum  in  this  neighbor- 
hood  forms  a  double  concave  surface,  due  to  its  direction,  its  long  di- 
ameter, and  its  cylindrical  shape. 

On  a  correct  appreciation  of  this  fact  rested  the  success  of  this 
operation.  I  soon  ascertained,  by  experimenting  Avith  a  tenaculum, 
that  if  I  should  denude  a  portion  of  rectal  surface  of  a  uniform 
width,  in  two  parallel  lines,  from  one  opening  to  the  other,  that  I 
w'ould  not  be  successful  in  forming  a  urethral  canal.  This,  doubtless, 
was  the  most  obvious  mode  of  procedure,  and  yet  it  was  evident  that 
if  these  freshened  surfaces  were  turned  over  and  brought  in  contact, 
there  would  result  a  narrowing  in  the  centre  in  the  shape  of  an  hour- 
glass contraction.  In  order,  therefore,  to  reconstruct  the  membranous 
portion  of  the  urethra  in  this  case,  it  was  necessary  to  remove  the 
raucous  membrane  from  the  rectal  surface  in  the  form  of  an  elliptical 
space,  as  shown  in  diagram  Fig.  114.  Four  of  the  sutures  are  there 
represented  to  have  been  introduced  for  the  purpose  of  showing  that 
Avhen  these  were  tied  the  undenuded  spaces  A  B,  Fig.  114,  would 
form  a  canal  of  uniform  width,  and  the  line  of  union  would  lie  in  the 
direction  C  i>  in  the  long  axis.  Now  Fig.  115  is  supposed  to  repre- 
sent a  recto- vaofinal  fistula  viewed  from  the  rectum.  The  mucous 
membrane  of  the  rectal  surface  is  shown  to  be  denuded  in  an  elliptical 


662  DIFFERENT    FORMS    OF    FISTULA. 

form,  as  in  Fig.  ll-i,  but  with  the  long  diameter  of  the  ellipse  cross- 
wise. 

The  direction  of  the  ellipse,  represented  in  Fig.  114,  was  demanded 
by  the  necessities  of  this  special  case,  and  is  exceptional.  With  a 
circular  rectal  fistula  the  ellipse  should  always  extend  across  the  long 

Fig.  115. 


Eecto-urethral  fistula  in  a  man  (urethral 
surface). 


Recto-uretliral  fistula  in  a  man  (rectal 
surface). 


diameter  of  the  rectum,  as  shown  in  Fig.  115,  in  which  the  sutures 
are  represented  as  introduced  in  the  same  maimer  as  in  the  preceding 
figure.  It  is  evident  that  in  Fig.  115  the  two  surfaces  A  B  would 
be  turned  over  and  become  a  portion  of  the  vaginal  surface  when  the 
sutures  were  secured  in  the  line  CD.  Care  must  be  exercised  to 
bend  the  sutures  properly,  so  that  they  shall  lie  flat  to  the  rectal 
surface  with  their  free  end  directed  somewhat  towards  the  outlet,  so 
as  to  avoid  catching  portions  of  fecal  matter,  which  would  prove  a 
source  of  irritation.  Moreover,  bending  their  ends  in  this  direction 
enables  the  sponge  which  had  been  placed  at  the  sigmoid  flexure  to 
be  withdrawn  without  disturbing  their  position.     The  sutures  should 


RECTO-VAGINAL    FISTULA.  053 

remain  about  eight  days,  and  no  special  means  need  be  taken  to  con- 
stipate the  bowels  beyond  the  use  of  some  form  of  concentrated  food 
which  furnishes  little  residual  matter.  If  the  rectum  be  found  occu- 
pied by  feces  when  about  to  remove  the  sutures,  the  mass  must  be 
carefully  sponged  or  washed  away  with  a  jet  of  water  from  a  syringe, 
sufficiently  to  bring  the  sutures  into  view.  If  the  desire  to  have  the 
bowels  moved  had  been  urgent  previous  to  this  time,  a  dose  of  medi- 
cine administered  for  the  purpose  would  be  safer  than  to  distend  the 
rectum  with  an  enema. 

This  method  of  closing  a  fistula  from  the  rectal  side  is  only  applica- 
ble to  such  as  are  of  moderate  size  with  the  edges  bevelled  in  the  oppo- 
site direction,  showing  the  destruction  of  tissue  to  have  been  greatest 
on  the  vaginal  surface.  Whenever  the  sides  of  the  fistula  can  be 
brought  together,  the  opening  should  always  be  closed  from  the  vagina. 
This  is  the  simplest  of  the  two  methods,  and  the  one  most  likely  to  be 
successful,  since  there  is  more  danger  from  hemorrhage,  and  the 
sutures  are  more  liable  to  cut  out  from  rectal  than  from  the  vaginal 
tissue.  By  making  an  incision  on  each  side  of  the  opening,  parallel  to 
the  axis  of  the  canal,  the  edges  of  a  fistula  may  often  be  made  to  drop 
easily  together  on  the  vaginal  surface,  and  without  subsequent  tension, 
even  in  unpromising  cases. 

I  have  seen  several  cases  where,  during  parturition,  the  child's 
head  had  been  left  pressing  on  the  perineum  so  long  that  a  circular 
slough  was  thrown  off,  destroying  the  neck  of  the  bladder,  part  of 
the  urethra,  and  leaving  a  rectal  fistula  just  behind  the  sphincter  ani. 
After  such  extensive  sloughing  a  cicatricial  band  sometimes  forms 
around  the  vaginal  outlet  and  across  the  remains  of  the  urethra.  In 
these  cases,  although  it  may  be  easy  to  bring  the  vesico-vaginal  fistula 
into  view"  and  to  close  it,  the  rectal  one  is  situated  so  close  behind  this 
band  that  unless  it  be  divided,  it  is  sometimes  impossible  to  bring  the 
opening  into  view.  This,  however,  must  not  be  cut,  for  the  neck  of 
the  bladder  is  lost,  and  there  remains  only  the  traction  from  this  band 
to  furnish  the  retentive  power,  which  it  does  by  keeping  the  sides  of 
the  urethra  in  close  contact.  In  such  a  case  the  opening  must  be 
closed  from  the  rectum,  or,  if  this  be  impossible,  reliance  must  be 
placed  on  the  sense  of  touch  to  accomplish  it  from  the  vaginal  side. 
I  was  obliged  in  one  case,'  through  fear  of  loss  of  the  retentive  power, 
to  close  such  an  opening  and  succeeded  in  freshening  the  edges  and 
in  securing  the  sutures  without  once  seeing  the  fistula. 

'  See  Case  No.  167  of  Abstract  of  Cases  of  Fistula,  in  this  work  (Case  LXVII.  in 
my  book  on  Vesico-Vaginal  Fistula). 


654  DIFFERENT    FORMS    OF    FISTULA. 

8.  Vesico-vagmal  fistulce  from  accidental  causes.  Under  this  head 
it  will  not  be  necessary  to  present  more  than  the  history  of  two  cases 
which  cannot  be  classified  elsewhere.  The  occurrence  of  the  accident 
from  pelvic  abscess,  and  from  calculi  cutting  through  into  the  vagina 
from  the  bladder,  will  be  treated  of  later. 

Case  XLVII. — A  vesico-vaginal  fistula  behind  the  left  ramus, 
caused  by  pressure  of  a  pessary  which  had  been  worn  for  five 
years. 

Miss  M.,  aged  47,  from  Rush,  N.  Y.,  consulted  me  May  19,  1866. 
She  came  under  the  observation  of  Dr.  Hammond,  of  her  neighborhood, 
some  two  years  before,  in  consequence  of  incontinence  of  urine,  from 
which  she  had  begun  to  suffer  a  short  time  previous.  He  removed 
from  the  vagina  a  corroded  "horse-shoe"  pessary,  one  limb  of  which 
had  entered  the  bladder.  She  had  been  ignorant  of  the  fact  that  any 
instrument  had  ever  been  introduced,  and  had  not  been  examined  for 
over  five  years  previous  to  its  removal.  An  attempt  was  made  to 
close  the  opening  by  the  use  of  caustic,  but  without  success.  The 
doctor  then  operated,  but  succeeded  only  partially,  and  recommended 
her  afterwards  to  consult  me. 

An  opening,  through  which  a  No.  12  bougie  could  be  easily  passed, 
was  found  situated  behind  the  left  ramus  at  the  bottom  of  the  sulcus 
formed  on  that  side  between  the  lateral  wall  and  the  base  of  the 
bladder.  The  edges  of  the  fistula  were  thin  and  tense,  being  formed 
entirely  of  cicatricial  tissue,  and  to  this  condition  the  failure  of  the 
operation  was  doubtless  due. 

May  22.  The  opening  was  closed  by  nine  sutures.  It  was  evi- 
dent that  no  union  could  be  obtained  by  bringing  together  the  cica- 
tricial edges  of  the  fistula,  nor  could  this  tissue  be  removed  bodily,  in 
consequence  of  the  locality  being  in  close  proximity  to  the  large 
vessels  running  along  the  sulcus.  Under  the  circumstances  the  vaginal 
surface  on  each  side  of  the  sulcus  was  freshened  in  either  direction,  at 
some  distance  from  the  opening,  but  as  near  the  edge  as  possible 
without  including  the  cicatricial  tissue.  The  surface,  when  thus  de- 
nuded, represented  a  long  oval,  about  an  inch  and  a  half  in  length, 
and  less  than  an  inch  in  width.  As  the  sutures  were  twisted,  a  fold 
of  the  lateral  wall  was  doubled  down  over  to  the  base  of  the  bladder. 
This  inclosed  the  fistula  in  a  long  pouch  below,  but  from  the  position 
and  shape  of  the  cavity  it  was  impossible  for  a  drop  of  urine  to  remain 
after  the  bladder  had  been  emptied. 

June  1.  Five  sutures  were  removed,  but  the  others  not  until  June 
9,  as  the  tension  exerted  by  bringing  the  surfaces  together  was  suffi- 
cient to  make  it  advisable  that  they  should  remain  longer. 

12th.    She  sat  up,  and  on  the  l9th  inst.  she  returned  home,  cured. 

Case  XLVIII. — Vesico-vaginal  fistula,  resulting  from  a  pistol-ball 
which  entered  the  thigh  and  passed  from  the  vagina  through  the  blad- 
der and  abdomen ;  no  union  after  the  first  and  second  operation,  from 
the  occurrence  of  cystitis.     Third  operation  successful. 


ACCIDENTAL    VESICO -VAGINAL    FISTULA.  655 

Miss  H.,  aged  25,  Avas  admitted  to  the  Woman's  Hospital,  from 
Virginia,  Nov.  8, 1866,  with  the  following  history.  In  March,  1865, 
while  resisting  the  attempt  of  a  soldier  to  buckle  a  holster  of  pistols 
around  her  waist,  a  navy  revolver  fell  out,  and,  on  striking  the  floor, 
it  was  discharged  with  the  muzzle  upward.  As  a  number  of  persons 
were  in  the  room  at  the  time,  she  did  not  inform  her  friends  that  she 
had  been  injured,  and  the  fact  was  not  known  until  she  fainted  from 
loss  of  blood. 

On  examination  it  was  ascertained  that  the  ball  had  entered  the 
right  thigh,  and  passing  into  the  body,  was  found  lodged  immediately 
under  the  skin  on  the  left  side  just  above  the  crest  of  the  ilium.  She 
was  confined  to  her  bed  for  five  Aveeks,  during  which  time  the  track 
of  the  ball  through  the  thigh  healed,  but  with  incontinence  of  urine 
remaining.  Several  months  afterward  Dr.  Fisher,  of  Warrenton,  Va., 
operated  for  the  purpose  of  closing  the  vesico-vaginal  fistula,  but 
without  success,  in  consequence  of  the  condition  of  the  bladder  and 
the  cicatricial  edges  of  the  opening. 

I  found  the  point  of  entrance  into  the  right  thigh  was  about  five 
inches  below  Poupart's  ligament,  and  two  inches  outside  of  the  femoral 
artery.  The  ball  had  crossed  the  course  of  the  artery  and  entered 
the  pelvis  and  the  vagina,  apparently  through  the  thyroid  foramen, 
thence  obliquely  into  the  bladder,  perforating  its  base  in  the  median 
line,  about  midway  between  the  neck  and  cervix  uteri.  After  ex- 
amining the  bladder  carefully  with  a  sound,  quite  a  prominent  fold,  or 
ridge,  was  felt  on  its  posterior  wall,  stretching  across  the  cavity  just 
above  the  line  of  peritoneal  reflection  from  the  bladder  to  the  uterus. 
It  was,  therefore,  evident  that  the  ball  had  escaped  from  the  bladder 
at  this  point  into  the  peritoneal  cavity,  and  striking  the  uterus  ob- 
liquely below  the  fundus  had  glanced  ofi"  nearly  at  a  right  angle,  and, 
passing  among  the  intestines,  lodged  under  the  skin  just  below  the 
crest  of  the  ilium  on  the  left  side.  The  fistula  was  nearly  circular, 
and  still  large  enough  to  admit  the  first  joint  of  the  index  finger.  Its 
edges  were  tense  and  formed  of  cicatricial  tissue  extending  to  some 
distance  from  the  opening. 

It  was  evident  that  at  the  time  of  the  accident,  the  bladder  con- 
tained but  a  small  quantity  of  urine  ;  it  was  immediately  emptied, 
and,  remaining  in  this  condition,  in  consequence  of  the  opening  below, 
no  urine  escaped  into  the  abdominal  cavity.  The  point  of  exit  was 
soon  closed  by  adhesive  inflammation,  while  the  bladder  was  in  a 
collapsed  state,  with  one  portion  lying  doubled  on  another  at  this 
point,  thus  forming  the  fold  felt  with  the  sound. 

The  ball  was  easily  removed,  and  I  still  have  it  in  my  possession  ; 
it  was  conical  in  shape,  and  weighed  half  an  ounce. 

Nov.  9.  On  the  day  after  her  arrival,  as  she  was  apparently  in 
excellent  condition,  I  operated,  and  was  assisted  by  Dr.  Fisher. 
There  was  no  difficulty,  an  anaesthetic  was  not  used,  and  the  opening 
was  closed  by  nine  interrupted  silver  sutures.  On  the  third  day  the 
urine  became  phosphatic,  and  it  was  with  great  difficulty  that  the 
catheter  could  be  kept  sufficiently  free  from  mucus  to  allow  of  the 


656  DIFFERENT    FORMS    OF    FISTULA. 

free  passage  of  the  urine.  On  the  sixth  dav,  the  urine  began  to 
escape  by  the  vagina,  but  only  in  small  quantities.  The  sutures  were 
removed  on  the  eighth  day,  and  it  was  then  found  that  no  union  had 
taken  place,  for  the  edges  separated  as  soon  as  the  sutures  were 
withdrawn.  From  the  fact  that  the  edges  had  been  brought  together 
readily  without  tension,  the  cause  of  failure  was  attributed  to  the  long 
and  tedious  journey  which  she  had  taken  just  pre\'ious  to  the  operation. 

Dec.  26.  The  fistula  was  again  closed  at  right  angles  to  the  long 
diameter  of  the  vagina  bj  thirteen  sutures,  the  patient  being  under 
the  influence  of  ether.  After  the  vomiting  depending  on  the  anaes- 
thetic had  ceased,  she  had  not  a  bad  symptom,  and  the  urine  all 
passed  by  the  catheter.  On  the  ninth  day  the  speculum  was  introduced 
for  the  purpose  of  removing  the  sutures,  but,  as  a  slight  moisture 
was  noticed  about  the  centre  of  the  line  of  union,  it  was  deemed 
advisable  to  allow  them  to  remain  a  few  days  longer. 

Jan.  9.  The  sutures  were  removed,  and  apparently  the  operation 
had  been  successful.  Wth.  The  use  of  the  catheter  was  discontinued. 
On  the  12th  she  sat  up,  and  had  perfect  control  of  the  urine. 

15£7i,  the  twentieth  day  after  the  operation,  she  was  examined, 
pronounced  cured,  and  made  her  preparations  to  return  home  in  a 
few  days.  Shortly  afterwards,  however,  possibly  in  consequence  of 
the  last  examination,  the  urine  began  to  escape  from  the  vagina. 
Gradually  the  edges  separated,  and  in  a  few  days  the  parts  were 
nearly  in  their  original  condition, 

March  31.  The  previous  operation  was  repeated,  but  without  an 
angesthetic,  and  thirteen  sutures  were  introduced.  A  few  days  after- 
wards, cystitis  came  on  as  in  the  first  instance.  The  sutures  were 
removed  April  9,  and,  although  but  little  had  been  gained  by  the 
operation  in  the  retentive  power,  the  fistula  was  reduced  to  half  its 
original  size. 

It  was  now  evident  that  the  recurrent  symptoms  of  cystitis  were 
due  to  inflammation  of  some  portion  of  the  bladder,  which  was  quies- 
cent so  long  as  the  urine  had  a  free  outlet  for  escape  at  the  most 
dependent  point.  With  the  cystitis  and  the  cicatricial  character  of 
the  tissue  fonning  the  edges  of  the  opening,  the  cause  of  failure  was 
evident.  It  was  directed  that  the  bladder  should  be  washed  out 
carefully  several  times  a  day  until  after  the  next  period.  A  large 
quantity  of  wann  water  Avas  used,  the  catheter  being  introduced 
through  the  urethra,  and  the  fluid  escaped  through  the  fistula  into 
the  vagina. 

May  25.  It  was  thought  that  her  condition  had  improved  sufficiently 
to  justify  another  operation,  which  was  performed  under  the  influence 
of  an  anaesthetic  in  the  following  manner.  A  point,  somewhat  in 
advance  of  the  old  line  of  union  was  seized  with  a  tenaculum,  and, 
with  scissors,  the  cicatricial  tissue  Avas  removed  in  a  single  piece, 
about  three-quarters  of  an  inch  wide,  so  as  to  include  the  entire  length 
of  the  vaginal  fistula.  The  opening  into  the  bladder  itself  was  not 
enlarged,  but  as  much  of  the  vaginal  tissue  as  possible  was  removed 
through  the  opening.    A  practical  point  was  involved  in  not  touching  the 


ACCIDENTAL    VESICO- V  A  GIN  AL    FISTULA.  657 

mucous  membrane  of  the  bladder ;  but  as  regards  the  value  of  this 
a  difterence  of  opinion  exists.  (When  the  vesical  surface  is  included 
in  the  denudation  I  am  quite  sure  that  the  risk  of  hemorrhage  is  in- 
creased, and  the  mucous  membrane  ten<Is  to  retract  from  the  edges  of 
the  vaginal  tissue,  thus  rendering  the  effective  introduction  of  sutures 
very  ditficult,  unless  they  are  passed  within  the  bladder.)  A  nucleus 
is  thus  frequently  furnished  for  the  formation  of  a  calculus,  and  often 
the  bladder  becomes  so  distended  with  a  clot,  as  to  render  it  neces- 
sary to  remove  the  sutures  to  arrest  the  bleeding.  I  have  already 
referred  to  a  fatal  termination  in  the  Woman's  Hospital  from  this  cause. 

To  relieve  all  tension,  the  edges  of  the  fistula  on  each  side  were 
put  on  the  stretch  by  a  tenaculum,  and  snipped  with  scissors  in  a 
parallel  line  along  the  vaginal  tissue,  somewhat  longer  than  the 
opening,  and  about  an  half  an  inch  from  its  borders.  Eleven  in- 
terrupted silver  sutures  were  introduced  farther  back  than  usual  from 
the  edges,  so  as  to  include  a  fair  portion  of  tissue,  and  the  line,  when 
secured,  was  about  an  inch  and  a  half  in  length. 

A  smaller  number  of  sutures  were  required  in  this  operation, 
although  the  opening  had  been  made  larger.  This  was  due  to  its  ob- 
long shape,  which  allowed  its  edges  to  close  naturally  together,  while 
the  former,  being  circular,  could  not  have  been  closed  without  forming 
on  the  vaginal  surface  a  puckering  fold  at  each  extremity.  To  obviate 
this  condition,  it  was  necessary  to  remove  a  portion  of  the  vaginal 
tissue  at  some  distance  beyond  each  end,  and  to  include  the  extended 
line  in  the  sutures,  as  already  explained,  until  the  fold  was  smoothed 
down  to  the  general  line  of  the  vagina. 

The  operation  was  finished  in  about  three-quarters  of  an  hour,  and 
with  but  little  bleeding,  as  the  scissors  had  been  used.  After  the 
bowels  had  been  opened  by  a  mild  cathartic  the  night  before,  the  su- 
tures were  removed  on  the  tenth  day.  Two  days  afterwards  she  sat 
up,  and  returned  home,  cured,  June  18. 


43 


658  STATISTICAL    HISTOKT    OF    YESICO-    AXD 


CHAPTER  XXXIII. 

STATISTICAL  HISTORY  OF  YESICO-  A^'D  RECTO-YAGIXAL  FISTULA. 

I  HAYE  had  nearly  four  hundred  cases  of  vesico- vaginal  fistula  under 
my  care,  in  public  and  private  practice,  but  unfortunately  the 
records  of  the  greater  portion  of  these  cases  are  not  available. 

The  twenty-second  annual  report  of  the  Woman's  Hospital  contains 
a  tabular  statement,  as  it  is  supposed  to  be,  of  all  the  diseases  which 
had  been  treated  in  the  institution  from  its  organization  in  April,  1855, 
to  the  end  of  the  year  1875.  This  report  was  prepared  by  Dr.  John 
A.  Beckman,  one  of  the  pathologists  of  the  institution,  and  from  his 
notes  I  have  been  furnished  ^"ith  the  material  which  will  be  presented 
on  this  subject. 

It  is  stated  that  two  hundred  and  eighty-nine  cases  of  vesico-  and 
recto-vaginal  fistula,  resulting  from  parturition,  had  been  treated  in 
the  institution  during  the  above  given  period. 

This  number,  I  am  confident,  contains  all  the  cases  which  had  been 
operated  on  by  the  other  surgeons,  who  have  been  connected  ^ith  the 
hospital.  Dr.  Sims's  record  I  kept  myself,  and  the  histories  of  the 
cases  operated  on  by  the  members  of  the  Medical  Board,  since  the 
chancre  of  organization  in  1872,  are  intact.  But  the  first  records  of 
a  portion  of  the  cases  which  were  treated  by  me  -were  never  copied 
into  the  case  book,  and  so  were  lost ;  and  I  have  been  able  to  estab- 
lish the  fact  that  the  records  of  at  least  fifty-seven  cases  of  fistula  are 
missincr,  on  account  of  the  unsettled  condition  of  affairs  in  the  institu- 
tion  previous  to  the  removal  of  the  patients  into  the  new  building. 

Dr.  Beckman  furnished  me  with  outline  histories  of  the  cases  on 
which  I  operated  after  Sept.  1,  1862,  when  I  took  charge  of  the  insti- 
tution, and  as  the  record  thus  stands,  I  have  treated  nearly  sixty  per 
cent,  of  all  the  cases.  But  Dr.  Beckman's  list  does  not  include  those 
of  which  the  records  have  been  lost,  nor  of  any  case  which  had  been 
admitted  during  the  time  of  Dr.  Sims's  ser\-ice,  but  treated  by  me. 
An  important  number  of  cases  have  been  also  excluded  which  had  been 
but  partially  benefited,  or  had  received  but  some  preparatory  treat- 
ment, during  the  above  period,  and  yet  years  after  they  came  under 
my  care  and  were  cured.     These  would  not  appear  on  the  hospital 


RECTO-VAOINAL    FISTULA.  659 

books  as  new  patients,  but  tlieir  records  would  be  continued  from  the 
date  of  their  first  admission.  Nor  have  I  been  credited  with  any  case 
treated  by  me  during  the  greater  portion  of  the  year  I  was  in  charge 
of  the  institution  during  Dr.  Siras's  absence  in  Europe,  and  previous 
to  his  departure.  I  believe  that  about  eighty  per  cent,  of  all  the  cases 
which  have  been  treated  in  the  Woman's  Hospital,  previous  to  the 
making  of  this  report,  were  under  my  charge. 

To  attempt  the  sifting  of  the  records  from  the  date  of  admission  of 
each  patient,  for  the  purpose  of  separating  those  which  had  been  under 
my  care  would  have  involved  an  almost  impossible  amount  of  personal 
labor,  and  was  deemed  unnecessary  in  view  of  the  material  already 
available,  including  only,  as  has  been  stated,  the  cases  operated  on  by 
me  after  Sept.  1,  1862,  to  the  date  of  the  report.  After  this  those 
still  under  treatment  were  excluded,  although  I  believe  all  have  been 
cured  since  that  date.  I  shall  also  use  any  material  needed  which  I 
may  have  already  presented  in  my  work  on  vesico-vaginal  fistula.  In 
private  hospital  I  have  treated  a  number  of  cases,  but  after  they 
ceased  to  be  a  novelty,  the  record  of  the  operation  and  after  treat- 
ment was  not  kept  with  accuracy,  unless  the  case  possessed  unusual 
interest- 

The  causes  are  thus  given  for  fistulge  opening  into  the  vagina  or 
rectum  in  such  cases  as  were  admitted  to  the  Woman's  Hospital  under 
my  care. 

Childbirth 171 

Syphilitic  sloughing  into  the  bladder        ......  1 

Cutting  of  a  pessary  into  the  bladder       ......  1 

Gunshot  wound  between  the  bladder  and  vagina     ....  1 

Sinus  of  an  abscess  opening  into  the  bladder  and  vagina         .         .  1 

Breaking  of  a  glass  syringe,  which  cut  into  the  bladder           .         .  1 

Accidental  incised  wounds        ........  3 

Removal  of  stone     ..........  7 

Relief  of  cystitis        ..........  16 

202 
The  proportion  is  5.84  per  cent,  for  recto-vaginal  fistula,  where  the 
lesion  has  resulted  from  childbirth.  For  the  present  it  is  unnecessary 
to  enter  more  into  detail  as  to  the  above  stated  causes  of  fistula,  unless 
to  make  some  reference  to  those  resulting  from  incised  wounds.  These 
cases  were  admitted  to  the  hospital  after  they  had  received  the  acci- 
dental injury.  In  one,  an  attempt  had  been  made  to  reach  the  uterus 
in  a  case  of  congenital  absence  of  the  vagina.  The  bladder  was 
entered,  and  the  case  will  be  found  detailed  in  the  chapter  on  "Absence 
of  the  vagina."    In  the  second  case  a  portion  of  the  recto-vaginal  sep- 


660 


STATISTICAL    HISTORY    OF    VESICO-    AND 


IS 


•pa 


^ 


I 

e 


r-t 

C5 

o 

'^ 

a  o 

O 

t-^ 

CJ 

c-i 

<-i 

CO 

oi 

c-i 

,_J 

u" 

n 

CO 

-3 

-t< 

IJ5  2 

-* 

p 

^ 

^^ 

'^ — ' 

o 

o 

Id 

1-H 

03 

R 

m 

• 

o 

o 

I-t 

LT^ 

CO 
CO 

I— 1 

• 

1—1 

1^ 

in 

o 

O 

o 

I— f 

CO 

J>; 

o 

o 

(M 

o 

o 

t-1 

1-5 

irj 

CO 

1-1 

CO 

O 

o 

-^ 

CO 

o 

CO 

t^ 

o 

o 

^ 

CO 

T—t 

1-1 

C3 

CO 

(M 

■^ 

"^r~ 

O 

o 

C3 

i—i 

CO 

o 

o 

o 

CO 

o 
d 

-* 

o 

o 

o 

00 

r}< 

CO 

in 

(M 

o 

m 

c4 

CO 

CO 

1—1 

CO 

-* 

o 

o 

in 

t- 

-* 

CO 

C^] 

o 

r-l 

o 

r^ 

ci 

1—1 

(M 

o 

T-1 

1—1 

CO 

CO 

lO 

CI 

o 

?o 

CO 

CD 

(M 

CO 

^ 

o 

^ 

-* 

1—1 

cq 

CO 

o 

o 

-* 

un 

lO 

t~ 

o 

o 

o 

CO 

^ 

^ 

CO 

in 

CO 

CD 

o 

'>^ 

o 

^ 

to 

CO 

o 

vn 

1—1 

Ci 

o 

ci 

m 

-* 

"^ 

CO 

CO 

CO 

-* 

Ir^ 

CO 

I— 1 

^ 

OO 

'i' 

00 

(M 

I-l 

CO 

CO 

CO 

oi 

(N 

ci 

CO 

^ 

C5 

?M 

-o 

cq 

^ 

o 

CO 

CO 

•^ 

lO 

M 

cq 

■^ 

C5 

m 

>* 

1—1 

rH 

^ 

C-1 

CO 

,_^ 

^ 

CO 

-* 

I-l 

ir3 

t^ 

CO 

CO 

CO 

CO 

"*. 

CO 

Ci 

t-^ 

C5 

00 

co' 

'^ 

-o 

(M 

M 

^ 

im 

>, 

. 

S 

£ 

O 

b 

o 
to 

•2 

• 

i 

2 

.'s 

s 

13 

• 

s 

■^ 

o 

2 

ci 

o 

<►-. 

f— • 

> 

^ 

t4 

© 

o 

j: 

o 

To 

^ 

1) 

© 

o 

;:^ 

^ 

"rt 

g 

a 

;^ 

c 

^ 

^ 

t^j 

-*^ 

^ 

^ 

'o 

rt 

c 

o 

© 

© 

ri 

^ 

rt 

/2 

rO 

^ 

'" 

s 

« 

.fl 

c 

c 

*j 

-t-» 

?4-* 

p 

© 

3 

1 

o 

rt 
o 
to 

c! 

© 
to 

P 

o 

o 

■-5 

o 
to 

f— t 

o 

13 

© 
to 

c 
to 

,2 

s 

c3 

<4- 

o 

"o 

ci 

rt 

a 

^ 

s 

© 

© 

^ 

^ 

> 

d 

d 

> 

> 

"fC 

^ 

Ph 

<5 

J5 

^ 

<j 

<1 

RECTO-VAaiNAL    FISTULA.  661 

turn  had  been  cut  through  in  an  operation  for  vaginismus.  In  the  third 
instance  the  bladder  was  opened  in  an  attempt  to  divide  cicatricial 
bands  which  partially  closed  the  vagina. 

I  shall  now  confine  myself  to  a  consideration  of  this  injury  as  the 
result  of  childbirth. 

By  Table  LIII.  it  is  shown  that  171  women  were  injured  from  their 
first  to  their  fifteenth  lal)or,  and  the  percentage  for  each  labor  is  also 
indicated.  The  important  fact  is  brought  out  that  about  half  of  all  who 
suffer  from  this  lesion  are  injured  in  the  first  labor,  and  that  with  each 
succeeding  labor  the  liability  is  lessened.  The  average  duration  of 
labor  computed  from  rupture  of  the  membranes  as  the  most  certain 
indication  that  labor  had  begun,  was  58.69  hours  for  the  total  number, 
and  for  the  completion  of  the  first  labor  this  average  is  greater  than 
for  any  other.  The  average  age  at  the  time  of  admission  was  31.34 
years,  which  is  an  indication  that  the  injury  is  generally  sustained  at 
a  comparatively  early  period  of  life.  The  average  age  of  marriage 
as  taken  on  the  total  number  is  not  greatly  in  excess  of  the  general 
average  on  all  women.  But  for  those  who  were  injured  in  the  first 
and  second  labors  it  is  sufficiently  in  excess  to  indicate  that  the  rather 
late  marriage  of  a  number  of  women  may  have  some  relation  to  the 
accident.  We  may  interpret  these  averages  to  indicate  that  the  first 
labor,  without  being  at  so  advanced  an  age  as  to  have  seriously 
jeopardized  the  life  of  the  woman,  was,  nevertheless,  with  many,  suffi- 
ciently late  to  have  caused  the  progress  to  be  retarded  through  want 
of  elasticity  in  the  soft  parts. 

Only  sixteen  children  were  borne  by  all  these  women  after  the  re- 
ception of  the  injury,  and  there  were  a  few  miscarriages.  Althouo-h 
the  average  age  of  these  women,  when  the  fistula  was  formed,  was 
comparatively  early  yet  they  had  then  borne  478  children ;  and, 
although,  as  a  rule,  they  were  sterile  afterwards,  it  is  evident  this  con- 
dition was  the  result  of  the  accident,  since  the  average  was  already 
2.79  children  for  each. 

The  number  of  women,  mode  of  delivery,  and  average  time  in  labor 
are  shown  in  Table  LIV.,  together  with  the  percentage  of  those 
delivered  by  the  different  methods.  About  46.19  per  cent,  w^ere 
delivered  by  forceps,  and  their  average  duration  of  time  in  labor  was 
68.55  hours.  These  women  were  much  longer  in  labor  than  those 
delivered  by  any  other  means,  Avith  a  single  exception,  Avhich  is 
doubtless  due  to  the  comparatively  small  number  of  those  terminated 
by  traction  after  the  head  had  been  born  and  pains  had  ceased. 
Attention  is  particularly  called  to  this  fact,  and  its  significance  in 


662 


STATISTICAL    HISTORY    OF    VBSICO-   AND 


"^ 


s 

"<s> 


^ 


-^ 


s 


^ 


■" 

^ 

g 

^^ 

cs 

CO 

'O 

o 

to 

to 

CO 

o 

i-H 

ei 

o 

r-* 

»"* 

I—* 

CM 

CO 

u 

■^ 

CO 

■* 

CO 

r-< 

'-' 

" 

■^ 

O 

s 

■^ 

A, 

'0  M 

;  o 

:o 

tM 

.^ 

;  o 

Hi 

-<- 

.  O 

.  o 

.  o> 

.  O 

.  o 

.  o 

to 

'  cc 

•  ^ 

•  ^ 

•  r-\ 

*  CO 

•  CO 

•  cyD 

•   -M 

■  t"? 

CO 

;^ 

.  ^ 

I'*' 

;  ''^ 

;  M 

l-t  ^ 

^% 

Oi      ' 

t^     • 

<N     • 

CO      . 

e<<    • 

<M      • 

Ol     . 

-^        . 

CO      ■ 

p^ 

n 

^"    \ 

cc     • 

'"'    I 

^ 

a 

■a 

, 

*  S 

fe  g 

a 

o 

o 

^ 

CO 

CO 

^ 

«^. 

CO 

■^ 

»o 

o 

d  "^ 

CO 

8 

o 

o 

r-  "^ 

r-4 

o 

-r 

. 

,      , 

o 

(M'^i 

I— 1  ^ 

-* 

CO 

-M 

— H 

CO 

o 

o 

rH  '^ 

040 

-^ 

'^ 

t^ 

tti 

§ 

o 

o 

o 

o 

<M« 

eoo 

CO 

<o 

o 

s 

cq 

CO 

o 

o 

o 

OjO 

rH      • 

t- 

<o 

r- 

OD 

■o 

o 

■o 

oo" 

1-1=' 

^    , 

^t-. 

ro 

■o 

-^ 

■^ 

rfl 

CO 

o 

o 

o 

(N« 

rH      • 

r-* 

s? 

CO 

•* 

o 

CO 

^ 

en 

^ 

o 

o 

o 

o 

O 

«<= 

1-1  c 

rH  <=> 

i-c  "=" 

ttlO 

<N=> 

-+« 

00 

00 

>o 

-i> 

■* 

(S 

■* 

^ 

o 

o 

O 

o 

a 

CO 

rH-f 

„<o 

eoo 

a"". 

1— 1  ^ 

(M  "^ 

rJlO 

l-<» 

»0  CO 

r2 

■«" 

CO 

CO 

f-"  o 

t^ 

CO 

to 

'J" 

tj 

o 

o 

.   -) 

^ 

.a 

^ 

Si 

■  ^ 

•^ 

,a 

,n 

^ 

^ 

S9 

e.2 

ci2 

0^ 

0^ 

g-3 

g- 

s-^ 

C3^ 

rtj2 

ci2 
1.2 

a 

e.a 

S.2 

e.a 

e,?. 

S.2 

E.S 

6  =^, 

a 

"^a 

In 

^  F1 

^H 

^  a 

^a 

^fl 

^  S 

^ 

o  -" 

o  •" 

o  ■" 

o  ■" 

c  -■ 

O  " 

o  ~- 

o  *-■ 

o  ■" 

o  -^ 

o  ■" 

^ 

u    ® 

1-  <» 

t-  aj 

t.  o 

M    <D 

U    Ol 

U    OJ 

U    CJ 

>-    CJ 

^ 

OJ  bo 

»    60 

E  to 

cj  bo 

O   tD 

»  to 

o  to 

01  to 

,Q  ca 

,C    rt 

.O   :« 

^  d 

rC     3 

a 

s  ."; 

6  S 

S^, 

B!;: 

SS 

S  !i^ 

£  S 

B  m 

a  S 

H  v. 

"a  ir, 

wi 

a  > 

S     > 

s  > 

3    > 

3    > 

0  > 

s  > 

s  > 

s  > 

=  > 

=  t>- 

^-< 

*^.  <; 

>^<) 

'^,< 

^<1 

>5<) 

;?;^. 

;?-. -^ 

f^< 

r<< 

f5< 



•^^ 

■^ — 



s^^ 



^-'-^ 

— 

-'^'^ 



>.rv-w 

,0 

^ 

X 

^ 

^ 

«:  a 

s 

d 

42 

a 

a 

'S 

hi 

e  2 

2  ° 

si 

b 

k 

o  " 
0   X 

o 

tH 

; 

P 

1 

W 

>  o 

t; 

W 

f 

RECTO-VAGINAL    FISTULA.  663 

reference  to  the  popular  belief  that  fistula  is  a  result  of  instrumental 
delivery.  It  must  also  be  noted  how  large  a  proportion  of  these 
cases  were  terminated  bj  the  unaided  eiforts  of  nature :  and  particu- 
larly that  the  average  duration  of  labor  was  much  less  under  this 
mode  of  delivery.  Two  exceptions  will  be  noted  where  delivery  took 
place  in  a  much  shorter  period  of  time,  but  the  number  is  too  small 
to  have  any  weight.  The  circumstance  may  be  accepted  as  an  indi- 
cation that  neither  the  occurrence  nor  extent  of  injury  is  due  alone 
to  the  length  of  labor. 

An  explanation  must  be  made  in  regard  to  what  may  seem,  from  a 
casual  glance,  to  be  an  error  in  this  table.  Among  the  eighty-five 
women  who  received  the  injury  in  the  first  labor,  there  were  three 
delivered  by  forceps  and  two  by  craniotomy,  where  the  time  in  labor 
was  not  noted.  The  average  duration  of  labor  is  taken  on  the  real 
number,  but  the  total  one  is  given  to  avoid  confusion. 

If  it  were  shown  that  medical  men  had  been  in  charge  of  these 
women,  the  above  table  would  indicate  great  neglect  or  ignorance. 
But  for  the  credit  of  the  profession,  I  am  happy  to  state,  my  investi- 
gations on  this  point  are  most  satisfactory.  Whether  the  injury  was 
sustained  in  Europe  or  in  this  country,  but  few  women  received  medi- 
cal care.  The  history  of  many  shows  that  they  were  attended  by 
irresponsible  women,  or  had  no  one  until  at  the  last  moment,  when  a 
regular  practitioner  was  called  in  to  efl'ect  the  delivery.  With  but 
very  few  exceptions  have  I  failed  in  tracing  out  some  reasonable 
cause  for  the  injury,  where  the  case  had  been  attended  by  a  medical 
man  throughout  the  progress  of  the  labor.  As  the  exceptions  to  the 
rule,  however,  some  flagrant  instances  of  gross  neglect  and  of  unpar- 
donable ignorance  were  made  evident. 

Beyond  question,  in  the  majority  of  cases,  a  neglect  to  empty  the 
bladder  has,  by  retarding  the  progress  of  labor,  proved  an  indirect 
cause  of  vesico-vaginal  fistula. 

Table  LV.  includes  a  certain  number  of  cases  where  the  bladder 
had  been  properly  emptied  throughout  the  time  of  labor.  With 
others  the  bladder  was  not  evacuated,  and  the  average  is  given  in 
hours  for  the  length  of  time  the  retention  existed.  A  few  of  these 
women  were  doubtful,  from  the  fact  that  they  suffered  from  puerperal 
fever,  or  were  unconscious  for  a  length  of  time,  but  the  probabilities 
are  all  in  favor  of  the  supposition  that  retention  existed.  With  a 
large  number  of  cases  no  record  was  made  on  this  point. 

After  looking  over  the  averages,  as  given  in  Table  LV.,  or  if 
the   time   of  retention  be  noted,  one  can  but  be   astonished  at  the 


664 


STATISTICAL    HISTORY    OF    VESICO-    AND 


o 

'<S> 


8    Srj 


■^ 


Rq 


J>- 

^ 

(M 

t^ 

P-l   o 

CO 

CO 

C5 

CO 

o 

«o 

cq 

^ 

" 

i-H 

cq 

lO 

<D 

.-* 

.o 

.  c^ 

p'* 

•  r^ 

•  as 

•  o 

•  CO 

Fh 

00 

lo     • 

»o     • 

CO 

O    S 

C^ 

■^     • 

Ci 

fr  2 

-u    = 

o 

cq  -^ 

I— 1 

S.2 

CO 

b 

3 

cq 

o 

rnP 

•     . 

CO 

•     • 

o 

rnO 

•     • 

1— 1 

•     • 

c 

: 

t-t 

1     : 

•      • 

•     • 

1     • 

■ 

t^ 

•             •      •             I      I         rH 

(M 

•     • 

1-i 

•     • 

O 

O 

"«*^ 

(N 

CO 

1^ 

cq 

CO 

r-H 

I-H 

o 

O 

CO 

OM 

rH  O 

O 

CO 

cq 

o 

o 

CO 

oci 

co'^ 

-* 

■" 

I— 1 

CO  CO 

o 

CO 



•   t< 

•     ^^ 

o 

o 

•    r^ 

•     r=! 

.    ci 

.    rt 

,—1 

•     ^4-1 

•    C4-( 

o 

o 

> 

•^ 

S.2 

"=  o 

'" 

"*                 -, 

rt   rt 

d    rt 

O     t-i 

i 

bo 

"o  ■^ 

•s^ 

o    > 

d   i- 

'i 

^2-1 

^.-1 

■    -^ 

1/ 

^-v«-' 

"— Y~^ 

ri 

■*-' 

a> 

^ 

^ 

a 

e 

a 

c     . 

^ 

V. 

o 

>?: 

o 

a 

« 

« 

Q 

^ 

-TS 


^3 


^i^ 


fci 


t^ 


i-i 


^"^f^s 

/-s 

>  s 

(^ 

Wi       to 

«xs 

■75 

5^    ^ 

.S 

cc     o 

>^ 

S     ^ 

(I 

O  ►< 

e  ^ 

'tS 

0) 

> 

< 

-^ 

ti) 

•—^ 

-« 

=C 

o 

^ 

Tj* 

CO 

cq 

cq 

C3 

CO 

p,  g 

0 

0 

C5 

(M 

'^ 

cq 

o 

be   . 

.  C3 

•ft? 

,  1-; 

< 

*  1— 1 

^ 

o  a 

0 

0        • 

1—1 

t^       • 

El  = 

a 

o  ? 

0 
^^<=> 

cq 

f^.C 

cq 

^  1    • 

:  : 

rH 

•  • 

0 

^ 

r-l 

nlO 

'"' 

CO 

• 

i-< 

c 

I— 1              •       ■ 

t^ 

' 

0 

1— 1 

cqo 

>o 

0 

■* 

i-H 

^ 

0 

C5 

cq<= 

CO 

0 

rH 

0 

CO 

cqO 

0 

I— 1 

■-1  CI 

0 

CO 

rH   <^ 

r-i 

r-( 

^  r-i 
1— 1 

C>-3 

0 

V         .       . 

--^ 

■\ 

.§ 

'   in 

P! 

s 

<» 

s  a 

ea 

> 

^ 

oj 

■5 

rd 

c3  -^ 
0    i) 

0 

^ 

g^ 

as 

^ 

OJ 

£ 

0) 

;^H<1 

u 

c« 

!-.     > 

;3  t- 

S   a> 

s 

0  ^ 

'^b 

1-^ 

c 

c 

6  = 

0  'Tj 

^ 

W 

>^ 

RECTO-VAGINAL    FISTULA.  C)Q5 

capacity  of  the  female  bladder.  The  statement  so  often  given  that 
"  the  urine  escaped  as  soon  as  the  head  was  delivered  by  the  forceps" 
is  not  necessarily  an  indication  of  harm  done  by  the  instrument,  but 
conclusive  evidence  of  neglect  on  the  part  of  the  operator  to  empty 
the  bladder.  While  no  special  harm  may  accrue  to  the  mother  from 
this  neglect,  it  is  evident  that  the  life  of  the  child  is  placed  more  in 
jeopardy  by  the  delay  and  increased  difficulty  of  delivery,  on  ac- 
count of  the  space  occupied  by  an  over-distended  bladder.  The 
object  of  Table  LV.  is  to  draw  attention  to  the  condition  of  this 
viscus.  So  far  as  stated  the  figures  are  reliable,  but  cannot  be  ac- 
cepted as  an  indication  of  the  frequency  with  which  urine  is  allowed 
to  accumulate.  In  nearly  every  instance,  as  given  in  the  table,  when 
any  positive  information  was  obtained  I  had  made  the  record  myself, 
and,  excluding  the  93  cases  in  which  my  assistants  neglected  to  ob- 
tain information  in  regard  to  this  matter,  it  seems  probable  that  in 
at  least  half  of  the  cases  the  bladder  was  not  emptied  during  the  pro- 
gress of  the  labor.  This  proportion  is  very  likely  even  under  the 
average. 

In  Table  LVI.,  it  is  shown  that  with  a  large  proportion  of  cases, 
there  was  no  loss  of  urine  for  days  after  delivery.  It  is  evident, 
therefore,  that  death  of  the  soft  parts  takes  place,  forming  a  slough, 
which  requires  a  certain  time  before  it  can  become  separated  from  the 
healthy  tissue.  This  impresses  me  with  the  belief  that  if  the  bladder 
were  always  evacuated  before  delivery,  the  loss  of  urine  would  only 
occur  after  a  slough  had  come  away,  and  never  at  the  time  of  delivery, 
unless  there  were  a  laceration.  It  is  not  improbable  that  even  the 
extent  of  sloughing  might  be  greatly  limited  by  measures  to  remove 
the  additional  source  of  irritation. 

It  is  shown  in  Table  LVI.  that  with  29.24  per  cent,  the  urine  es- 
caped from  the  moment  of  delivery.  With  40.93  per  cent.,  the  loss 
of  urine  did  not  take  place  for  a  long  period  after  termination  of  the 
labor.  While  in  51  cases,  or  29.82  per  cent.,  it  was  neglected  to  make 
any  record. 

After  further  investigation,  the  proportion  may  vary  somewhat  as 
to  the  number  of  cases  with  escape  of  urine  at  birth,  or  after  a  certain 
time.  But  the  average  here  shown  in  seventy  cases,  as  to  the  separa- 
tion of  the  slough  after  the  tenth  day,  is  likely,  since  from  so  large  a 
number,  to  be  a  near  approach  to  the  rule. 

If  the  testimony  of  these  w^omen  can  be  relied  upon,  as  to  the  fre- 
quent neglect  to  use  the  catheter  before  resorting  to  instrumental 
delivery,  the  question  would  naturally  present  itself  as  to  cause  and 


6QQ  STATISTICAL    HISTORY    OF    VESIC.O-    AND 

effect.  The  average  time  is  so  long  before  the  separation  of  the 
slough  takes  place,  that  it  is  not  improbable,  with  many  cases,  the 
exciting  cause  of  the  inflammation,  which  ends  in  sloughing,  had  its 
origin  in  the  additional  force  necessary  to  effect  the  delivery,  while 
the  bladder  was  over-distended. 

That  so  well  known  a  necessity  should  be  neglected,  before  attempt- 
ing the  operation  of  artificial  delivery,  seems  almost  incredible.  But 
I  find  this  omission  was  quite  as  common  abroad  as  in  this  country, 
and  by  a  class  of  men  who  would  never  have  neglected  such  a  pre- 
caution in  private  practice.  The  only  explanation,  if  it  can  be  ac- 
cepted as  one,  is  the  hasty  rendering  of  a  gratuitous  service,  with  no 
previous  responsibility  of  the  case,  and  with  the  single  purpose  of 
accomplishing  the  delivery  with  the  least  loss  of  time.  We  must 
also  bear  in  mind  how  frequently  women  of  this  class  will  mislead  us 
through  their  lack  of  intelligence.  Moreover,  after  impaction  takes 
place  a  woman  is  often  able  only  partially  to  empty  the  bladder  by  her 
own  exertions,  and  may  deceive  herself  as  to  its  true  condition. 
Therefore,  there  can  be  but  one  safe  course  to  pursue  and  that  is 
the  introduction  of  a  male  catheter,  or  an  elastic  one  in  every  case, 
without  any  regard  to  the  statement  of  the  patient. 

But  under  some  conditions  the  head  may  so  fill  up  the  pelvis  as  to 
render  the  introduction  of  the  catheter  an  impossibility,  unless  such 
force  be  employed  as  might  cause  a  false  passage  or  lead  to  inflam- 
mation of  the  urethra.  If  the  forceps  can  be  applied  this  difficulty 
may  be  easily  overcome,  as  the  head  may  be  lifted  up  or  turned  to 
one  side  sufficiently  to  admit  of  the  introduction  of  a  catheter.  De- 
livery should,  therefore,  never  be  attempted  until  after  the  bladder 
has  been  emptied,  since  the  child  would  be  likely  to  be  lost  and  the 
neck  of  the  bladder  lacerated.  Should  it  be  impossible  to  apply  the 
forceps  or  to  introduce  the  catheter,  the  bladder  must  be  aspirated. 
This  operation  has  been  frequently  performed  on  the  male,  by  passing 
a  fine  trocar  just  above  the  pubes,  so  as  to  enter  the  bladder  below 
the  dip  of  the  peritoneum,  and  it  has  been  done  without  the  slightest 
bad  consequences.  I  should  hold  this  to  be  the  proper  course  of 
treatment  so  long,  at  least,  as  the  child  was  alive,  and,  even  if  crani- 
otomy should  be  performed  afterwards,  the  space  thus  gained,  by 
emptying  the  bladder,  would  prove  advantageous.  But  we  have  no 
right  to  sacrifice  the  life  of  the  child,  even  if  the  mother  be  in  danger, 
so  long  as  there  is  a  possibility  of  saving  both  with  little  increase  of 
risk  to  the  mother.  Therefore,  the  bladder  must  be  emptied  first, 
and  before  the  next  step  can  be  decided  upon.     The  progress  of  labor 


RECTO-VAGINAL    FISTULA.  667 

is  frequently  retarded,  and  even  arrested,  by  a  distended  bladder,  yet 
delivery  often  takes  place  promptly  through  the  efforts  of  nature  alone 
after  the  accumulation  has  been  removed. 

In  Table  LVI.  the  condition  of  the  bladder,  in  regard  to  the 
retention  of  urine  a;nd  the  time  of  the  separation  of  the  slough,  is 
shown  in  connection  witli  the  number  of  operations  required  after- 
wards to  remedy  the  injury.  It  would  be  a  difficult  point  to  establish 
that  the  number  of  operations  bears  any  relation  to  the  duration  of 
the  retention,  since  so  large  a  proportion  of  cases,  it  will  be  seen,  are 
thus  cured  by  one  operation,  without  any  regard  to  the  actual  loss  of 
tissue.  The  retention  of  urine,  as  has  been  suggested,  might,  at  the 
time  of  delivery,  necessitate  a  resort  to  great  force,  liable  to  be  fol- 
lowed by  bad  consequences.  But,  in  all  probability,  the  mere  reten- 
tion itself  would  not  lead  to  extensive  injury.  The  force  would  be 
directed  chiefly  against  the  neck  of  the  bladder,  ivhen  a  laceration 
might  occur,  if  a  slough  did  not ;  but  the  danger  of  extension  of  the 
injury  would  cease  as  soon  as  the  slightest  opening  took  place. 

Having  considered  the  value  of  an  over-distended  bladder  as  a 
factor  in  the  production  of  vesico-vaginal  fistula,  with  the  degree  of 
proportionate  injury  to  the  retentive  power,  we  naturally  pass  to  the 
study  of  the  different  modes  of  delivery  as  employed  after  greater  or 
less  delay. 

The  facts  recorded  in  Table  LVII.  evidently  show  that  instru- 
mental delivery  has  but  little  to  do  with  the  formation  of  fistula.  At 
the  first  glance  it  would  appear  that  the  extent  of  injury  was  due  to 
the  time  of  labor.  This  seems  to  be  shown  on  taking,  for  instance, 
those  delivered  by  forceps,  where  the  time  in  labor  is  increased  and 
the  number  of  operations  greater.  It  may  be  true  that,  under  certain 
circumstances,  the  longer  a  woman  is  allowed  to  remain  undelivered, 
the  greater  will  be  the  risk  of  extensive  injury  to  the  soft  parts. 
But,  as  a  rule,  it  is  a  matter  of  doubt  whether  the  extent  of  injury 
bears  any  relation  whatever  to  the  length  of  labor.  This  will  be 
made  evident  after  the  most  casual  examination  of  the  "abstract  table 
of  cases  of  vesico-vaginal  fistula."  Beginning  with  the  first  one  of 
the  record,  Avhere  labor  lasted  but  twenty-four  hours,  the  result  was 
sach  a  destruction  of  tissue  as  to  retjuire  twenty  operations  and  three 
years  of  treatment  to  complete  the  restoration.  Case  No.  76  was 
in  labor  but  eight  hours  and  a  half,  and  yet  the  sloughing  was  very 
extensive.  On  the  other  hand,  Case  No.  148  is  shown  to  have  been 
undelivered  eight  days,  yet  sustained  comparatively  slight  damage ; 
and  so  other  cases  might  be  cited. 


668 


STATISTICAL    HISTORY    OF    VESIGO-   AND 


5> 
5- 


<§- 
^ 

^ 


e 
^ 


^ 


^ 


f^ 


'S^ 
tS 


> 

w 
a 

H 


, 

c3  i 

o 

^1 

p'--? 

CO  ^ 

i~o 

^  ^} 

iM'-? 

coO 

(MO 

M'T 

m« 

'^'t 

coO 

,_, 

CO 

rj* 

c:3 

^ 

C-l 

t^ 

i< 

o 

c 

^ 

1 

o 

o 

o 

J^ 

CO 

P5       t> 

0                  " 

'^ 

Tti 

-J 

O 

e 

1 

^1 

o 

-t.  > 

1-H    O 

Tt< 

CO 

^ 

'^  c 

C4 

o 

o 

g  > 

o  '^ 

(M  ^ 

-J-q 

^^ 

o 

:  : 

O 

~* 

c 

-■ 

,^ 

Ol 

CO 

o 

o 

^ 

r:. 

^ 

o<^ 

l^'^. 

cq  >-■; 

co"= 

l-H  => 

I-.0 

coO 

o 

C-1 

r-i  ,-j 

c 

-^ 

J:~ 

o 

*"* 

- 

o 

o 

o  a 

S.S 

o 

c              " 

1-1 

ei 

•     • 

o 

t^  o 

d 

CI 

"* 

o 

r-^ 

-:J< 

o 

1^ 

rH   O 

r-H 

CO 

^^ 

t> 

^  o 
d 

" 

o 

o 

^' 

C-1      . 

o 

CO 

CO 

o 

o 

O 

^ 

<M  -; 

CI  o 

l-C  =• 

(© 

-H 

•^ 

"^ 

c^ 

o 

o 

O 

O 

eoo 

Cl=i 

■^ 

o 

o 

•* 

CI 

C35 

■"* 

o 

O 

CO 

o 

o 

c8 

CO 

C5 

cc  ^ 

co=^ 

rH  '^ 

CO  CO 

coO 

Ci 

CO 

'"" 

CO 

CO 

o 

IM 

CO 

■9" 

o 

1-^ 

o 

^ 

■^ 

r~a= 

<^:° 

•*q 

o<^l 

<N«5 

eqo 

«;0 

I-H   « 

CO      • 

-Toi 

^o 

(M 

INCJ 

o 

'" 

"* 

CI 

■"^ 

d 

t^ 

P4 

L( 

^ 

(j 

•  u, 

>    ^ 

\^ 

•    t- 

Ui 

o 

o 

o  =• 

m-^ 

m-^ 

»;  J 

^ 

m-^ 

m-^ 

%   o3 

n 

r<:-° 

m'=' 

i^ 

S  "^ 

c   ^ 

o  ^ 

g  d 

oS 

s  ^ 

2  j3 

S  ji 

OS  rt 

c3   d 

OS  3 

03  d 

03   d 

oJ  d 

ci  d 

03   d 

c4   d 

oi  d 

ci  d 

^ 

C 

"o  £ 

O    t. 

tw    09 

«.-.     9? 

o 

.  3 

.   3 

.  d 

.  d 

.  S> 

.  d 

.  d 

.  3 

.  3 

.  d 

.  d 

g 

o  o 

o  o 

o  o 

o  o 

o  o 

^ 

;^s 

'^n 

y,-A 

^  3 

t^W 

^3 

^a 

fen 

>5a 

!2:M 

>^3 

%-. 

<= 

^                      hrf-v-W 

»---->• 

^^-v-^rf 

^^^.^.^^ 

..•-v-^/ 

\-»-v-W 

»^-v-^^ 

v^-V-^/ 

.^-v-^ 

t* 

o 
o 

HI 

a 

^ 

■^  ^ 

•T3 

d 

d    . 

a 

d 

.2 

oi 

13   « 

■S   3 

a 

3 
d 

o 

0!    o, 

'o  9 

w 

'3 

c2 

•S  2 

O   o! 

.2 

u 
o 
r- 

Is 

o 

a 

w 

3  d 

^<2 

"3  i; 
O  -.J 

^  d 
o 

o 

"^ 

RECTO-VAGINAL    FISTULA.  G69 

To  establish,  beyond  question,  the  effect  of  instrumental  delivery 
in  these  cases  is  a  most  important  matter  from  a  modico-legal  point 
of  view,  since  suits  for  malpractice  have  been  institute<l  on  the  plea 
of  damage  sustained  through  want  of  dexterity  on  the  part  of  the 
attending  physician.  A  plea  of  this  sort  has  been  successfully  prose- 
cuted, proof  being  advanced  that  the  urine  escaped  only  at  the  moment 
of  delivery,  and,  although  the  evidence  might  be  conclusive  to  a  jury, 
there  exists,  in  reality,  no  connection  whatever  between  the  supposed 
cause  and  effect. 

The  damage  is  usually  inflicted  by  the  impaction  of  the  child's 
head  causing  an  obliteration  of  the  circulation  in  the  soft  parts  of 
the  mother.  Half  an  hour  of  this  obstruction  may  cause  the  most 
extensive  loss  from  sloughing.  When  the  urine  escaped  at  the 
moment  of  delivery  the  damage,  with  scarcely  an  exception  to  the 
rule,  had  already  been  done,  and  a  slough  formed,  which  became 
loosened  only  as  the  head  was  withdrawn. 

I  do  not  hesitate  to  make  the  statement  that  I  have  never  met  with 
a  case  of  vesico-vaginal  fistula,  which,  without  doubt,  could  be  shown  to 
have  resulted  from  instrumental  delivery.  On  the  contrary,  the  entire 
weight  of  evidence  is  conclusive  in  proving  that  the  injury  is  a  conse- 
quence of  delay  in  delivery. 

Since  the  loss  is  not  in  proportion  to  the  length  of  the  labor,  as  has 
been  stated,  and  Ave  cannot  judge  of  the  degree  of  impaction,  there  is 
but  one  safe  course  to  adopt  and  that  is  to  effect  a  speedy  delivery. 
I  have  for  years  taught,  that  so  long  as  the  head  recedes  after  a  pain 
the  patient  can  be  in  little  danger,  notwithstanding  the  time  of  labor 
may  have  been  prolonged.  The  jeopardy  to  the  patient  begins  from 
the  moment  when  the  head  becomes  stationary,  and  then  the  child 
should  be  removed  as  speedily  as  possible.  Just  as  the  head  leaves 
the  uterus  and  while  the  neck  is  still  grasped  there  will  of  course  be 
no  recession  for  the  moment.  But  the  head  in  this  condition  is  too 
low  to  cause  damage  at  the  superior  strait,  and  has  not  yet  reached 
the  inferior  one.  The  rule  then  is  applicable  Avhen  the  head  and 
shoulders  have  already  escaped  from  the  uterus,  and  the  presenting 
part  has  begun  to  touch  the  floor  of  the  pelvis.  At  this  stage,  when 
the  head  no  longer  recedes  after  each  pain  it  is  proof  positive  that  the 
soft  parts  of  the  mother  have  lost  their  natural  resiliency,  and  that 
delivery  must  be  brought  about  speedily. 

I  do  not  pretend  to  lay  down  a  fast  rule  for  the  experienced  obstet>- 
rician  as  to  the  earliest  period  at  which  it  is  advisable  to  effect  delivery, 
nor  do  I  wish  to  advocate  a  more  frequent  use  of  instruments.    These 


670 


STATISTICAL    HISTORY    OF    VESICO-   AND 


points  must  be  determined  by  the  attending  physician  in  each  case. 
But  it  is  well  to  establish  some  general  rule  for  the  guidance  of  those 
whose  experience  is  more  limited,  and  I  believe  the  indications  above 
presented  will  be  found  to  be  applicable  in  a  large  majority  of  cases 
of  protracted  parturition. 

Table  LVIII Mode  of  Delivery,  Time  under  Treatment,  and  Result. 


Mode  of  delivery. 

'6 
9 

6 

o 
> 
o 
u 

p. 

a 

'6 

o  2 

^  p. 

B 

•a 

Hi 

67 
ie.82 

6 

34.83 

7 
12.42 

11 

14.45 

2 
9.00 

3 
7.33 

1 
36.00 

9 
8.33 

27 
19.63 

13 

14.92 

5 
25.30 

2 

16.00 

1 
8.00 

1 
6.00 

1 
4.00 

74 
17.13 

6 
31.  S3 

12.42 

14 
14.07 

2 
9. 03 

3 

7.33 

1 
36.00 

9 
8.33 

32 
21.37 

13 
14.92 

By  forceps,     ^  ^^^  ^.^^^g  under  treatment  (weeks) 

Ergot.           ^  ^^_  ^.j^Q  under  treatment  (weeks) 

2 

1 

forceps.         \  Av.  time  under  treatment  (weeks) 

Craniotomy.     ^  '^^   ^^^^  under  treatment  (weeks) 

craniotomy.      \  Av.  time  under  treatment  (weeks) 

2 

Version.        ^  ^^_  ^^j^g  under  treatment  (weeks) 

forceps,         \  Av.  time  under  treatment  (weeks) 

Traction.     |  ^^   ^:^^^  under  treatment  (weeks) 

nature          <  Av.  time  under  treatment  (weeks) 

.'34.00 

4.00 

78.00 

very  not  given.  \  Av.  time  under  treatment  (weeks) 

14G     1       9 

3 

1 

2 

161 

I  have  claimed  that  any  one  who  is  familiar  with  the  mechanism  of 
labor,  although  wanting  in  practical  experience,  would  do  less  damage 
in  applying  the  forceps  in  such  a  case  than  would  result  if  the  delivery 
were  left  unaided.  It  will  be  shown  that  the  women  who  were  delivered 
by  means  of  instruments,  after  impaction  of  the  head,  sustained  far  less 
damage  to  the  soft  parts  then  those  in  whom  labor  was  hastened  by 
ergot,  or  terminated  by  the  unaided  efforts  of  nature.  By  reference 
again  to  Table  LVII.  it  will  be  seen  that  the  average  duration  of 
labor  for  those  women  who  were  delivered  by  instruments  was  greater 
than  that  of  those  in  which  the  delivery  was  left  to  nature.  The 
number  is  greater  for  the  primipara  ;  in  fact  nearly  two-thirds  of  all 
the  injuries  occurred  in  the  first  labor.  It  is  also  shown  that  those 
labors  in  which  forceps  were  used  were  nearly  three  times  as  long  as 
those  in  which  no  aid  was  rendered.     From  so  great  a  difference  in 


RECTO-VAGINAL    FISTULA.  671 

the  average  duration  of  labor  for  the  two  classes  of  cases  it  would  be 
natural  to  suppose  that  the  destruction  of  tissue  would  be  compara- 
tively slight,  and  the  time  under  treatment  less  for  those  who  were 
delivered  without  aid.  It  is  not  within  my  province  to  enter  into  a 
discussion  of  the  relative  advantages  of  forceps  and  of  the  unaided 
efforts  of  nature  for  terminating  tedious  labors.  But  the  fact  cannot 
be  questioned,  nor  can  it  be  reiterated  too  often,  that,  after  impaction 
has  taken  place,  far  more  damage  will  result  from  leaving  the  head  to 
be  forced  out  by  the  action  of  the  uterus,  than  would  occur  from  any  form 
of  instrumental  delivery.  Table  LVIII.  clearly  demonstrates  this,  if 
we  accept,  as  an  indication  of  the  extent  of  injury,  the  average  dura- 
tion of  treatment  there  shown  to  have  been  necessary  before  the  injury 
was  repaired.  This  is  made  even  more  clear  in  Table  LIX.,  which 
does  not  include  those  aided  by  ergot,  those  left  to  nature,  or  those  for 
whom  the  mode  of  delivery  was  not  given.  We  have  thus  one  hundred 
and  ten  women  in  whom  labor  was  terminated  by  artificial  means ; 
and  there  is  also  shown  the  number  of  weeks  they  were  under  treat- 
ment. The  average  duration  of  treatment  for  one  hundred  women 
cured  was  15.24  weeks,  and  for  the  total  number  regardless  of  the 
result  it  was  15.48  weeks.  By  reference  again  to  Table  LVIII.  it 
will  be  seen  that  the  average  time  under  treatment  for  those  who 
were  cured  after  having  been  delivered  by  the  efibrts  of  nature  was 
19.63  weeks,  and  21.37  weeks  for  all  of  this  class  who  were  under 
treatment.  Thus,  those  who  were  cured  were  one  month  longer  under 
treatment  than  those  who  were  not  cured,  and  required  an  additional 
operation.  Those  who  were  delivered  by  the  efforts  of  nature  averaged 
about  six  weeks  longer  under  treatment  than  those  who  were  delivered 
through  artificial  means. 

Although  the  number  who  were  delivered  through  the  use  of  ergot 
alone  is  very  small,  as  shown  in  Table  LVIII.,  and  the  averages  ob- 
tained from  such  would,  under  ordinary  circumstances,  be  of  little 
value,  yet  they  are,  in  this  connection,  not  without  importance.  If 
there  is  greater  danger  in  allowing  the  delivery,  after  impaction,  to 
be  accomplished  by  dint  of  uterine  contractions,  it  is  shown  to  be  still 
more  so  where  these  have  been  increased  by  use  of  ergot.  There 
were  six  such  cases,  and  they  averaged  over  thirty-four  weeks  under 
treatment,  in  contrast  to  fifteen  weeks,  in  round  numbers,  for  the  cases 
cured  who  had  been  delivered  through  artificial  means.  In  other 
words,  these  cases  were  nearly  five  months  longer  under  treatment 
than  those  delivered  by  instruments,  and  over  three  months  longer 
than  those  who  were  left  to  the  efforts  of  nature. 


672 


STATISTICAL    HISTORY    OF    VESICO-    AND 


Table  LIX Showing  average  Duration  of  Treatment,  and  the 

Result  for  all  who  xocre  Delivered  by  Instruments. 


Cured.      Improved,  iniproved. 

Died. 

Result  not 
given 

Total. 

ll 

3  ^ 

&5 

Is 

-  ^ 

a  o 

^  S 

o  to 

pQ  a 

67 
11 

3 

1 
9 

1127        5 

129 
32 

1 

S 

I 

e 

1    !            4 

74 
7 

14 
2 
3 
1 
9 

1263 
S7 
197 
IS 
22 
3G 
75 

S7 
159 
18 
22 
33 
75 

2 

Version  and  craniotomy  . . 

Version 

Version  and  forceps 

Total  number  of  -women  . . 

Total  number   of  -nroe'^s 
under  treatment 

100 

1.321 

7 

161 

1 

s 

1 

G 

1 

4 

110 

17C3 

Average  time  under  treat- 
ment, in  weeks 

15.24 

22.85 

s.oo 

6.00 

4.00 

15.43 

These  facts  should  serve  to  remove  much  of  the  prejudice  which 
still  exists  against  instrumental  delivery.  While  it  may  be  true  that 
instruments  are  often  resorted  to  without  any  urgent  necessity,  still 
we  must  not  ignore  the  consequence  of  allowing  labor  to  be  too  pro- 
tracted. Vesico-vaginal  fistula  cannot  occur  as  the  consequence  of  a 
slough,  if  delivery  is  always  brought  about  as  soon  as  the  head  fails 
to  recede  after  each  pain. 

About  fifty  per  cent,  of  all  the  children  are  stillborn  in  labors 
which  result  in  vesco-vaginal  fistula.  This  is  shown  in  Table  LX.,  and 
also  that  the  proportion  of  deaths  is  about  the  same  whether  the  child- 
ren Avere  delivered  by  forceps  or  through  the  efforts  of  nature.  The 
average  duration  of  labor  for  these  cases  was  62.39  hours.  The 
average  time  in  labor  for  those  delivered  without  aid  was  46.73  hours, 
and  66.07  hours  for  those  in  whom  labor  was  terminated  by  artificial 
means.  The  average  is  given  on  both  the  time  in  labor  and  that 
under  treatment  for  each  mode  of  delivery,  so  that  a  comparison  can 
be  readily  made. 

It  was  noted  that  thirty  of  these  stillborn  children  were  of  a  re- 
markable size,  and  that  two  weighed  sixteen  pounds  each.    Tlie  average 


RECTO-VAGINAL    FISTULA. 


673 


on  the  total  number,  -where  the  weight  was  stated,  is  a  fraction  over 
fourteen  pounds,  which  is  beyond  question  erroneous  and  exaggerated. 
The  greater  portion  of  these  children  were  males,  which  are  gene- 
rally larger  than  female. 

Table  LX — Mode  of  Delivery,  and  Time  under  Treatment,  for  cases 
in  which  the  Children  were  Stillborn. 


Ai. 

^^  ^      ^  a 

a 

bi 

«  3  1  "       -  § 

uH 

3 

s  >  s     «  S-  • 

,a 

o 

-o 

-a 

o 

g.C    o       .a  j*^ 

T}   O 

d 

d 

o 

o 

3 

-3 
3-3 

=  3 

S5 

°  o   5.-  .S^  >? 

5^ 

o 

h 

o 

>.a 

f^ 

^p, 

d  a 

2_3 

o  -^  i  S  o  t  =^  =  »■ 

a  *j 
«  a 

o 
d 

o 

3 

II 

^.3 

11 

3"^ 

d  a 

ci  a 

53 

do 

=  ■2  g 

=  3  = 

!2; 

en 

< 

p 

iz; 

!zi 

<) 

25 

;S»|^ 

<« 

<( 

5 

6 

13 

2606 
320 
259 
695 

76.64 
64.00 
43.20 
53.33 

12 
4 
2 
4 

8 

2 
2 

6 

4 

4 

67.50 
86.25 

57.25 

20 
1 

4 

7 

13      16 

3       1 
3  '     2 

8.57 

2.00 

11.50 

10.16 

15.5S 
41.00 
13.50 
15.00 

Ergot 

Craniotomy 

6 

6 

Version  and  craniotomy 

1 

2S 

28.00 

1 

9.00 

Version 

2 
9 

23   13.00 
46   36.00 

•• 

1 

1 
0 

2 

7.50 

Traction:  delivery  of  body  ) 
after  birth  of  head \ 

8 

62-t 

78.00 

1 

1 

3 

71.33 

4 

3 

5 

11.00 

8.75 

By   the  unaided  efforts  of) 
nature 5 

15 

70] 

46.73 

7 

3 

4 

50.25 

8 

13 

10.84 

12.21 

Total  Xo 

S6 

62.39 

30 

17 

21 

66.33 

48 

30 

43 

9.87 

15.45 

A  comparison  can  be  made  between  Tables  LX.  and  LV.,  in  both 
of  which  the  condition  of  the  bladder  during  labor  is  noted.  It  is 
evident,  although  the  record  is  so  defective,  that  the  bladder  was  not 
emptied  in  a  large  proportion  of  the  women  who  bore  these  stillborn 
children.  As  the  bladder  was  over-distended  for  over  66.33  hours 
on  an  average,  we  may  readily  conceive  that  the  life  of  the  child 
would  thereby  have  been  frequently  lost  in  consequence  of  the  greater 
force  needed  to  terminate  the  labor.  Table  LVI.  shows  that  the 
urine  escaped  at  birth  in  29.24  per  cent.,  and  after  the  elapse  of  a 
certain  time  in  40.93  percent,  of  all  women  who  suffered  from  vesico- 
vaginal fistula.  Among  the  women  who  gave  birth  to  dead  children 
there  were  34.88  per  cent,  where  this  loss  of  urine  took  place  from  the 
moment  of  delivery.  On  the  other  hand,  with  50  per  cent.,  the  loss 
of  control  did  not  occur  until  after  an  average  interval  of  9.87  days 
from  the  time  of  labor,  when  a  slough  separated. 
43 


674 


STATISTICAL   HISTORY    OF    VESICO-   AND 


S 


^ 
^ 


^ 


^ 


'&i 


5=S 


pa 


•^  T-i      •  i-H 


ci 

i-H 

i    i    : 

:    :    : 

j       1       I  T-H       1      • 

(N 

o 

cq 

•  i-H  1-1 

:  ""^    : 

1    1 1— 1    1    ;    : 

CO 

cq 

(M 

s 

•      •       • 

rH 

t-i 

t-  CO  rH  1— I 


ci    jr-icqi—i    :i— I    irH    :  :    :    ; 

.      .      ^      .      .  •      ■  r^ 

^  r-l      ;  r-H  1-1      ;      ;  r-l      ;      :  ;  .  : 

in  (M 1—1    •  r-i    :    :  "-I    :    :  :    :    : 

in  cq    -1-1    •    I    :    :    :  "-I  :    :  ■"* 

cocococ^rHCOcq     ;     ;     ;  ;     ;     ', 

T— I  , . 


5  ^ 


RECTO-VAGINAL    FISTULA.  675 

The  women  giving  birth  to  stillborn  children  were  cured,  on  an 
average,  in  15.45  weeks,  which  is  less  than  that  taken  on  the  total 
number  of  women  with  fistula.  Excepting  for  those  delivered  through 
the  aid  of  ergot,  these  averages  are  all  lower  than  the  corresponding 
ones  of  the  women  who  had  given  birth  to  living  children.  We  have 
already  made  this  comparison,  showing  that  the  Avomen  with  whom 
the  labors  had  been  terminated  through  the  efforts  of  nature  were  a 
shorter  time  in  labor,  but  much  longer  under  treatment  than  those 
delivered  through  artificial  means. 

If  this  is  not  due  merely  to  the  small  number  of  this  class  the  fact 
is  almost  inexplicable. 

It  is  shown  by  Table  LX.  that  the  average  time  necessary  for  a 
woman  to  be  under  treatment,  Avhen  she  had  borne  a  dead  child  through 
the  efforts  of  nature,  was  nine  weeks  less  than  would  be  needed  if  she 
had  given  birth  to  a  living  child  without  assistance. 

It  can  be  readily  understood  that  the  risk  of  damage  to  the  mother, 
is  much  less  in  the  artificial  delivery  of  a  dead  child  than  that  of  a 
living  one  from  the  possibility  of  its  being  compressed  into  a  smaller 
mass. 

But  it  is  important  to  determine  the  stage  of  labor  in  which  the 
death  of  the  child  occurred,  for  it  is  scarcely  to  be  supposed  that  the 
unaided  uterine  efforts  could  expel  a  dead  child  Avith  less  damage  to 
the  soft  parts  of  the  mother,  than  would  be  inflicted  by  a  living  one. 

Table  LXI.  is  presented  as  a  part  of  the  history  of  the  lesion,  for  the 
purpose  of  showing,  in  connection  Avith  the  labor,  the  number  of  weeks 
these  women  A\ith  vesico-vaginal  fistula  Avere  under  treatment.  Thus 
6  women,  injured  in  their  first  labor,  and  2  in  their  third,  Avere  three 
weeks  under  treatment.  At  the  other  extreme,  one  case  Avas  260 
weeks,  or  over  five  years,  under  treatment  before  the  injury  could  be 
repaired. 

Of  the  total  171  cases,  the  largest  number  for  any  one  period  was 
30  women,  Avho  were  each  four  Aveeks  under  treatment. 

We  noAV  naturally  pass  to  consider  the  connection  betAveen  the  time 
in  labor,  the  required  number  of  operations,  the  period  under  treat- 
ment and  the  result.  Thus  by  Table  LXII.  it  will  be  seen  that  there 
were  one  hundred  Avomen  who  had  but  one  operation. 

Ninety  of  these  Avere  able  to  state  Avith  accuracy  the  time  in  labor 
(their  average  being  57.05  hours),  while  ten  Avere  unable  to  do  so. 

The  average  duration  of  treatment  for  one  hundred  Avas  8.38  weeks. 
Of  these  ninety- tAvo  who  were  cured  averaged  8.30  weeks  ;  four  Avere 
improved  after  a  certain  time  ;  two  Avere  not  benefited ;  one  died ;  and 


676 


;tatistical  history  of  yesico-  axd 


e 

s 


s 


^1 


2^ 


13 


CQ 


^l 

r-5  g       '"' 
1 

1-1 

^ 

1  sli  =ji 

,  1 

1 

o 
o 

a  l 

'.             o       : 

:          ec  o        : 

CO    c^* 

. 

.      : 

:    CO 

. 

t3  S 

<               ^        I 

^ 

' 

e-i        : 

!  ■ 

s 

-.     c 

i 

i 

i  . 

I 

- 

c 

1    *"" 
1 

? 

- 

1 

'  1  ■ 

i     cq  c 

3-1  '^ 

^ 

c 

1  . 

.  1 

1-1 

s 

1           g 

- 

5 

GO 

—    t 

1 

_ 

y 

•  1 

T— i      I. 

a- 

{      *, 

1 

c 

1  . 

rH  = 

: — i    I 

T         C 

\    >"■ 

;    c 

.            I 

c- 

a 

1 

S 

CO       c 

c 

. 

. 

^^  c; 

I-i    I. 

1     <- 

I— 1 

c 

t^- 

c 

• 

c_ 

i 

' 

„ 

1 

c 

c 

.       .1     : 

r^  "- 

ro  c^     — 

!        CT 

^H 

■ 

L 

1 

^ 

^ 

c 

c 

?3c: 

-o  s 

■>     o 

la 

c 

'.         I—! 

* 

^ 

r- 

c^       *^ 

oc 

,. 

i^ 

I 

'7'i  " 

m 

"rj^    - 

^^ 

ffs 

^ 

c 

^ 

1 —  — 

m  a: 

'J 

'        r^ 

^ 

c 

~ 

o 

1        ■ 

t- 

C 

c 

zc 

cr: 

•      o 

^a. 

CO 

cs  " 

c 

CO 

c 

'^ 

c 

I— 1 

o 

I-H 

Cs 

CC  - 

CO   g 

cc 

CO 

4- 

.-« 

',      ^ 

CO 

"" 

6 

1 

o  E 

'>     oc 

c 

~ 

o 

^ 

^ 

1       O  ^ 

o 

^      c 

£! 

•^ 

6 

cq 

1— ( 

c 

1— ( 

c 

C^  r> 

r^ 

s  ^.  °^ 

-i 

■^ 

ZC 

-r 

^; 

1 

'" 

1 

^ 

1       , 

^ 

1 

o 

rH 

O 

> 

'^ 

to 

P 

cr 

V. 

i      =^ 

rt 

^ 

'' 

^ 

■^ 

'to' 

'x 

'm 

,      ^ 

^ 

,:^ 

.!: 

^ 

.!> 

. 

,M 

"e 

o 

o 

C 

o 

c 

o 

zi 

— 

? 

^ 

& 

^ 

fe 

^ 

,     ^ 

■V               «« 

^ 

.« 

.1^ 

.fcj 

.«d 

C    ? 

^ 

c 

c 

c 

a 

a 

c 

e 

o 

C   3 

?^ 

c 

J 

J 

s 

j 

. 

S 

* 

t5  '- 

"S 

c 

1^ 

c 

1 

c 

ce    t- 

^ 

? 

t:  J 

;> 

^ 

*- 

h 

-^ 

■*^ 

•*• 

- 

u 

t4 

h 

»« 

c 

^^ 

n 

■§  = 

i 

1 

^ 

o 
•a 

13 

o 
•a 

o  = 

o 

a 

c 

c 

a 

a 

a 

"^   o 

e 

C 

S 

c 

e 

d 

u 

^  : 

^ 

"H^ 

c 

1       o 

I 

c 

E 

C 

°     1 

0         o 

i^ 

o 

11 

S 

c 

:^ 

c 

c 

^ 

c 

o 

K 

">   e 

1     •^ 

c 
>• 

>    i 
1 

& 
^ 

(S 

o 

1 

P. 

c 

6 

'II 

o 

<- 
u 

c 
d 

"  1 

c 

o 

^ 

o 

c 

O 

> 

> 

3 

s> 

Pi 

> 

>■ 

y 

tn 

^ 

< 

1   irf 

•< 

> 

o 

■< 

a 

< 

■< 

22 

•< 

o 

o 

a 

« 

^ 

•ri 

TJ 

3 

§ 

en 

h 
s 

1 

O 

o 

O 

o 

;z; 

Ci 

^ 

5 

/^^ 



RECTO-VAGINAL    FISTULA.  677 

in  one  instance  no  record  was  made  of  the  result  of  treatment.     58.53 
per  cent,  had  but  one  operation. 

It  is  shown  that  one  hundred  and  forty-nine  cases,  or  87.13  per  cent. 
were  cured,  so  many  improved,  not  improved,  etc.  Finally  for  the 
total  number  of  one-hundred  and  seventy-one  cases  of  vesico-vaginal 
fistula,  the  average  time  under  treatment  for  each  was  17.32  weeks. 

I  have  no  reason  to  be  dissatisfied  with  this  result.  A  large  number 
had  been  operated  on  before  Avithout  success,  and  owing  to  the  uni- 
versal knowledge  of  this  operation,  none  but  the  Avorst  cases  have  for 
many  years  been  sent  to  the  Woman's  Hospital.  I  claim,  however, 
that  we  may  confidently  look  for  still  better  results  by  some  10  per 
cent.,  as  the  operation  in  all  its  details  is  being  perfected  daily. 
Only  2.33  per  cent,  of  all  the  cases  I  have  seen  have  proved  incurable. 

Two  of  these  were  rendered  so  from  want  of  tissue,  the  uterus  and 
whole  vagina,  and  the  entire  tissues,  except  the  periosteum  behind  the 
pubes  and  ramus,  having  sloughed  away. 

A.  third  case,  a  negro  woman,  was  sent  to  the  "Woman's  Hospital  by 
Dr.  AVm.  Geo.  Thomas,  of  Wilmington,  N.  C,  who  had  detected  the 
difficulty  before  sending  the  case  to  me.  A  large  exostosis  existed  be- 
hind the  pubes,  and  somewhat  under  the  arch,  so  that  it  had  caused 
the  urethra  to  be  pushed  to  one  side.  This  growth  was  the  cause  of 
the  delay  in  labor,  by  which  the  whole  urethra,  with  the  tissues  under 
the  arch  of  the  pubes,  were  lost.  A  transverse  fistula  existed  at  the 
neck  of  the  bladder  which  could  have  been  closed,  but  under  the  cir- 
cumstances it  was  impossible  to  give  her  retentive  power.  The  fourth 
case  was  a  bad  one,  but  could  have  been  closed  but  from  the  fact  that 
she  was  so  excessively  fat  it  was  impossible  even  to  bring  the  parts 
into  view. 

The  eleven  cases  noted  as  simply  improved,  were  every  one  cured, 
or  could  have  been,  after  leaving  the  hospital,  by  some  additional 
operator.  The  openings  were  caused  by  the  accidental  cutting  out  of 
some  stitch,  and  in  several  instances,  I  am  satisfied  the  opening  closed 
by  contraction.  Finally,  the  single  death  resulted  from  advanced  dis- 
ease of  the  kidney,  and  the  operation  for  closing  the  fistula  was  but 
the  accident. 


678  CASES    OF    VESICO-VAGINAL    FISTULA 

ABSTRACT  OF  CASES  OF  YESICO-VAGINAL  FISTULA 

Treated  in  the  Woman's  Hospital. 

I Resulting  fro:m  Childbirth. 

The  Roman  numerals  indicate  the  numbers  home  by  the  cases  in  the  author's  monograph 
on  Vesico- Vaginal  Fistula. 

1  (lxiv.)-     ^(fm««eJ  Sept.  20,  1862.    Age  20.     Age  at  marriage  18.     No.  of  child- 

ren 1 ;  of  miscarriages  2. 
History.  In  labor  24  hours  :  head  born  in  10  hours  ;  body  14  hours  afterwards  ; 
stillborn  ;  11^  pounds  ;  ergot ;  bladder  not  emptied  for  84  hours. — Extent  of  Lesion. 
Base  of  bladder,  cervix,  and  urethra  destroyed  ;  vagina  shortened  and  contracted 
by  a  circular  slough  at  the  oniX^it.  — Treatment.  By  20  operations  for  opening  the 
vagina,  closing  the  fistula,  and  forming  a  new  urethra. — Duration  of  Treatment,  3 
years  ;  Result,  cured. — Remarks.  Had  cystitis  18  mouths  afterwards ;  bladder 
opened,  calculi  removed  ;  opening  not  closed  again. 

2  (xxvm.).    Admitted  Oct.  10,1862.    Age  25.    Age  at  marriage  24.    No.  of  child- 

ren 1. 
History.  In  labor  101  hours :  natural  delivery  ;  failed  in  applying  forceps ; 
bladder  not  emptied  ;  urine  escaped  from  delivery. — Extent  of  Lesion.  Loss  of  one- 
third  of  the  base  of  the  bladder  in  front  of  the  cervix  ;  fistula  concealed  ;  vagina 
shortened  by  anterior  lip  being  drawn  backward  from  contraction  of  cicatricial 
tissue  iu  the  posterior  cul-de-sac. —  Treatment.  Cicatricial  bands  divided  on  each 
side,  the  vagina  was  lengthened  an  inch,  and  fistula  brought  into  view  ;  closed 
by  8  sutures  ;  one  operation. — Duration  of  Treatment,  4  weeks  ;  Result,  cured. 

3  (lx.).     Admitted  Oct.  26,  1862.     Age  30.     No.  of  children  4. 

History.  In  labor  74  hours  :  delivered  by  forceps  ;  stillborn  ;  no  statement  as  to 
emptying  the  bladder ;  17  days  after  delivery  a,  slough  was  passed,  and  loss  of 
urine  followed. — Extent  of  Lesion.  A  triangular-shaped  fistula,  situated  behind 
left  ramus,  extended  across  the  vagina  to  the  opposite  side  of  the  cervix  ;  tlie 
edges  were  nearly  in  contact,  but  originally  there  had  been  great  loss  of  tissue. — 
Treatment.  To  bring  the  opening  into  view  and  to  close  it,  it  was  necessary 
to  dissect  its  base  free  from  the  bone ;  one  opwation  ;  5  sutures  ;  removed  9th 
day. — Duration  of  Treatment,  5  weeks  ;  Result,  cured. 

4.  Admitted  Oct.  29,  1862.     Age  33.     Age  at  marriage  29.     No.  of  children  1. 

History.  In  labor  50  hours  :  bladder  not  emptied. — Extent  of  Lesi.vi.  Fistula 
extended  from  the  middle  of  the  urethra  to  the  neck  of  the  bladder. —  Complica- 
tions. Vagina  contracted  from  a  circular  slough. —  Treatment.  7  operations  for 
opening  the  vagina,  closing  the  fistula,  and  forming  new  urethra. — Duration  of 
Treatment,  15  months  ;  Result,  cured. 

5  (xxvii.).     Admitted  l^ov.  24,  1862.     Ago  29.     No.  of  children  7. 

History.  In  labor  67  hours  :  natural  delivery  ;  stillborn  ;  large  child  ;  bladder 
not  emptied  for  43  hours  ;  urine  escaped  on  the  8th  day.  Injured  two  years  before 
admission. — Extent  of  Lesion.  Loss  of  the  whole  base  of  the  bladder ;  crescentic 
shaped  fistula,  with  the  corners  drawn  into  the  posterior  cul-de-sac  ;  cervix  formed 
the  posterior  boundary. —  Complications.  Cervix  lacerated  from  before^  backward. — 
Treatment.  Fistula  closed  with  19  sutures  ;  one  operation  ;  difiicult  on  account  of 
cicatricial  edges  ;  sutures  removed  9th  day. — Duration  of  Treatment,  4  weeks  ;  Result, 
cured. 

6  (xxxiv.).     Admitted  Dec.  11,  1862.      Age  31.      Age  at  marriage  19.       No.  of 

cliildren  2;  of  miscarriages  2. 
Hislori/.  In  labor  10  hours  :  forceps  ;  child  12  pounds  ;  bladder  not  emptied  ; 
injured  one  year  before  admission  ;  urine  escaped  3  weeks  after  d(divery. — Extent 
if  Lesion.  Fistula  oblique  from  the  right  of  the  cervix  to  tlio  left  of  the  neck  of 
the  bladder. —  Complicnttons.  I'regnant  3  months  when  admitted. —  Treatment. 
Extensive  dissection  of  tissue  necessary  to  fnM>  the  edges  ;  8  sutures  used ;  one 
operation  ;  sutures  removed  11th  day. — Duration  of  Treatment,  5  weeks  ;  Result, 
cured. 


RESULTING  FROM  CHILDBIRTH.  679 

7.  Admitted  Feb.  3,  1863.     Age  28.     Age  at  marriage  24.     No.  of  children  2. 

IJistori/.  In  labor  3(J  hours  :  stillborn  ;  progress  arrested  several  hours  ;  deliv- 
ed  by  efforts  of  nature  on  changing  position  of  head  ;  bladder  not  emptied  ;  slough 
passed  12th  day  ;  loss  of  urine  afterwards  ;  last  labor  three  years  before  admission. 
— Extent  of  Lesion.  Anterior  lip  of  the  uterus  sloughed  with  fistula  in  front  of  it ; 
on  account  of  the  position  of  the  uterus  and  shortening  of  tlie  vagina,  after  slough- 
ing, the  anterior  wall  formed  a  fold  in  front  of  the  opening  so  that  it  could  not  be 
brought  into  view  even  on  the  knees  and  elbows. — Complications.  Uterus  retro- 
verted  and  fixed  by  old  cellulitis. —  Treatment.  Split  the  anterior  wall  of  the 
vagina  tlirough  the  median  line  of  the  fold  into  the  fistula,  and  closed  all  as  one 
opening  ;  closed  all  but  a  small  opening  near  the  uterus  ;  several  operations  per- 
formed with  great  difficulty. — Result,  improved. — Remarks.  Never  returned  for 
final  operation. 

8  (xvui.).  Admitted  Feb.  7,  1863.     Age  30.     Age  at  marriage  19.     No.  of  child- 

ren 6. 
Histori/.  Instrumental  delivery  after  67  hours  in  labor  :  pocket-knife  and  a 
blunt  hook  used  ;  bladder  emptied  naturally  ;  loss  of  urine  fi-om  delivery.  Injured 
five  months  previous  to  admission. — Extent  of  Lesion.  Anterior  lip  lost  and  a  large 
portion  of  the  base  of  the  bladder  ;  by  cicatricial  tissue  the  vaginal  wall  was 
drawn  into  a  fold  so  as  to  hide  the  fistula  from  view  ;  the  cervix  projected  into  the 
bladder  through  the  fistula. —  Complications.  Uterus  retroverted  and  immovable 
from  old  cellulitis. —  Treatment.  As  the  uterus  could  not  be  moved,  the  crest  of 
the  fold  was  united  to  the  posterior  lip  with  9  sutures  ;  operation  successful ; 
afterwards,  a  small  opening  caused  by  traction  ;  closed  by  another  operation. — 
Duration  of  Treatment,  10  weeks  ;   Result,  cured. 

9  (xii.).     Admitted  March.  7,  1863.     Age  40.     Age  at  marriage  32.     No.  of  child- 

ren 2. 
Histori/.  Injured  in  the  second  delivery  ;  71  hours  in  labor  :  completed  by  the 
efi"orts  of  nature  ;  ergot ;  stillborn  ;  bladder  emptied  ;  slough  passed  two  weeks 
after  delivery ;  loss  of  urine  afterwards.  Injured  five  years  before  admission. — 
Extent  of  Lesion.  Laceration  of  the  anterior  lip  in  the  median  line,  with  sloughing 
of  nearly  two  inches  along  the  base  of  the  bladder  ;  the  vaginal  wall  was  drawn 
into  a  deep  fold  on  each  side  of  the  fistula. —  Treatment.  The  sides  of  the  fold  and 
of  the  tear  through  the  cervix  were  united  in  common  with  the  edges  of  the  fis- 
tula ;  eleven  sutures  ;  line  two  inches  and  a  half  in  length  ;  sutures  removed  10th 
day ;  one  operation. — Duration  of  Treatment,  6  weeks  ;  Result,  cured. 

10  (vi.).     Admitted  March  8,  1863.     Age  32.     Age  at  marriage  21.     No.  of  child- 

ren 6. 
Histori/.  In  labor  18  hours  :  delivered  by  version  ;  stillborn ;  bladder  emptied 
by  catheter;  urine  escaped  on  the  day  after  delivery  ;  injured  in  the  last  labor  ; 
delivered  by  forceps  in  her  previous  labors. — Extent  of  Lesion.  Laceration  of  the 
anterior  lip  of  the  cervix  uteri  and  base  of  the  bladder  in  the  median  line ;  par- 
tially closed  by  nature,  leaving  a  sinus  from  the  bladder  communicating  with  the 
cervical  canal  above  the  vaginal  junction.  —  Com/)lications.  Deep  double  lacera- 
tion of  cervix  laterally  from  a  previous  labor. —  Treatment.  Cured  by  uniting  the 
sides  of  the  laceration  and  thus  closing  the  os  uteri. — Duration  of  Treatment,  9 
weeks  ;  Result,  cured. — Remarks.  Could  now  be  cured  by  laying  open  the  sinus, 
removing  its  walls,  and  then  bringing  the  sides  together  with  sutures,  leaving  the 
OS  open. 

11.  Admitted  April  2,  1863.     Age  28.     Age  at  marriage  21.     No.  of  children  5. 

History.  Injured  in  tlie  fifth  labor  ;  96  hours'  duration  :  delivered  with  forceps  ; 
bladder  not  emptied  for  60  liours. — Extent  of  Lesion.  An  opening  an  inch  in  dia- 
meter extending  across  the  vagina  and  situated  just  in  front  of  the  cervix. — Com- 
plications. Cervix  destroyed. —  Treatment.  Os  turned  into  the  bladder  by  uniting 
the  anterior  edge  of  the  fistula  to  the  posterior  wall  of  the  vagina  ;  14  sutures 
removed  the  9th  day. — Duration  of  Treatment,  8  weeks  ;  Result,  cured. — Remarks. 
Had  been  operated  on  three  times  previous  to  admission. 

12  (xxxii.).     ^f/m/?W  April  13,  1863.     Age  20.     No.  of  children  1. 

History.     First  pregnancy  ;  in  labor  90  hours  :   delivery  by  forceps  ;  stilllwrn  ; 


680  CASES    OF    VESICO-VAGIXAL    FISTULA 

catheter  passed  regularly  ;  escape  of  urine  immediafelj  after  delivery. — Extent  of 
Lesion.  A  transverse  fistula  in  front  of  the  cervix,  an  inch  or  more  in  length, 
had  been  closed  by  a  previous  operation,  leaving  a  small  opening  admitting  a  probe. 
— Complications.  An  attempt  had  been  made  to  close  the  fistula  with  the  cautery, 
causing  cicatricial  tissue. —  Treatment.  Two  operations  ;  first  was  unsuccessful  on 
account  of  the  cicatricial  edges  ;  an  opening  one  inch  long  made  by  removing  this 
tissue  at  the  second  operation  ;  7  sutures,  removed  9th  day. — Duration  of  Treatment, 
8  weeks  ;  Result,  cured. 

13  (xLviii.).  Admitted  X^ril  27,  1S63.  Age  33.  Age  at  marriage  27.  IS"o.  of 
children  1. 
History.  In  labor  5  days  :  delivered  by  forceps  three  years  before  admission  ; 
bladder  emptied  twice. — Extent  of  Lesion.  A  transverse  fistula  at  the  neck  of  the 
bladder,  two  inches  in  length  ;  vagina  only  an  inch  deep,  occluded  above  the  fis- 
tula, retaining  menstrual  blood. —  Treatment.  Fistula  closed  by  one  operation 
with  8  sutures  ;  vagina  opened  five  times  with  the  knife  ;  succeeded  by  laceration. 
— Duration  of  Treatment,  21  months  ;  Result,  cured. — Rei/iarks.  History  of  case 
detailed  in  full  in  Chapter  on  Retained  Menstruation,  etc. 

14.  Admitted  May  30,  1863.     Age  32.     Age  at  marriage   30.     ^'o.  of  children  1 ; 
of  miscarriages  1. 
History.     In  labor  36  hours  :  forceps  ;  child  very  large  ;  bladder  not  emptied. — 
Extent  of  Lesion.     Fistula  in  the  median  line,  one  inch  in  length. — Treatment.    One 
operation  ;  6  sutures,  removed  8th  day. — Result,  cured. 

15  (li.).     Admitted  June  8,  1863.     Age   32.     Age  at  marriage  18.     Xo.  of  child- 

ren 2. 
History.  Sefeond  pregnancy ;  twins  ;  28  hours  in  labor :  first  delivered  by 
breech  ;  second  by  craniotomy. — Extent  of  Lesion.  Fistula  half  an  inch  in  dia- 
meter in  the  line  of  a  former  opening  resultiugfrom  the  first  labor. —  Complications. 
Antero-posterior  diameter  of  pelvis  2f  inches  ;  partial  occlusion  of  the  vagina. — ■ 
Treatment.  Vagina  dilated  by  sponge-tents  to  close  the  fistula  ;  8  sutures  ;  allowed 
to  contract  afterward,  to  prevent  impregnation. — Duration  of  Treatment,  9  weeks  ; 
Result,  cured. — Remarks.     First  fistula  was  closed  by  Dr.  Emmet,  July,  1862. 

16  (lvi.).     Admitted  Oct.  1,  1863.     Age  30.     Age  at  marriage  24.     ^'o.  of  child- 

ren 4. 
History.  In  labor  44  hours  :  natural  delivery  after  ergot ;  child  very  large ; 
stillborn  ;  bladder  was  emptied  regularly ;  loss  of  urine  after  24th  day. — Extent  of 
Lesion.  Triangular-shaped  opening  behind  the  left  ramus. —  Treatment.  Closed 
with  great  difficulty  by  6  sutures  ;  removed  8th  day. — Duration  of  Treatment,  4 
weeks  ;  Result,  cured. 

17  (lxvi.).     Admitted  Oct.  1,  1863.     Age  38.     Age  at  marriage  14.     No.  of  child- 

ren 8. 
History.  In  labor  84  hours :  delivered  by  forceps,  after  ergot ;  no  recollection 
of  emptying  the  bladder  ;  urine  lost  after  the  7th  day. — Extent  of  Lesion.  Loss 
of  one-third  of  the  lower  portion  of  the  vagina  just  beyond  the  neck  of  the  bladder, 
but  by  contraction  of  the  vagina  the  edges  lay  almost  in  contact,  and  extended 
from  one  ramus  to  the  other. —  Complications.  Rectal  fistula. —  Treatment.  Closed 
the  opening  with  11  sutures  ;  removed  on  the  8th  day  ;  required  several  months 
of  preparatory  treatment  before  operation. — Result,  cured. 

18.  Admitted  Oct.  5,  1863.     Age  41.     Age  at  marriage  28.     Xo.  of  children  4  ;  of 

miscarriages  3. 

History.     In  the  last  labor  1  hour  :  foot  presentation  ;  delivered  by  version. — 

Extent  of  Lesion.     Fistula  small ;  laceration  tlirough  the  anterior  lip  of  the  cervix. 

—  Treatment.'    By  two  operations. — Duration  of  Treatment,  7  weeks  ;  Risult,  cured. 

19  (xLiv.).     Admitted  Oct.  1,  1S63.     Age  35.     Age  at  marriage  14.     No.  of  child- 
dren  5  ;  of  miscarriages  1. 
History.     Injured  in  the  4th  labor,  of  7  hours  :  natural  delivery  ;  placenta  re- 
tained 12  hours  ;  urine  esc.api'd  from  time  of  delivery  ;   7  years  previous  to  admis- 
sion ;  last   child  5  years   after. — Extent  of  Lesion.     Loss  of  the  entire  base  of  the 


RESULTING    FROM    CKILDBIRTII.  G81 

bladder,  with  bands  extending  from  each  side  of  the  cervix  to  the  piibes  ;  vagina 
shortened,  the  cervix  being  near  the  neck  of  tiio  bladder,  and  listula  contracted 
to  an  inch  in  diameter. — Com/dicutiong.  Neck  of  the  uterus  drawn  into  the  bladder 
by  contraction  of  cicatricial  bands. —  Treatment.  First  operation  successful,  with  7 
sutures  ;  afterwards  an  opening  as  large  as  a  probe  occurred  Ixdiind  the  right 
ramus  ;  second  operation  unsuccessful  ;  third  one  successful  by  dissecting  the  tis- 
sues free  from  the  face  of  the  ramus. — Duration  of  Treatment,  13  weeks  ;  Result, 
cured. 

20  (liii.).     Admitted  Oct.  \%,  l^Q'i.     Age  32.     Age  at  marriage  20.     No.  of  child- 

ren 6. 
History.  In  labor  115  hours  :  forceps  ;  child  stillborn  and  very  large  ;  urine 
escaped  from  the  time  of  delivery.  Injured  six  months  previous  to  admission. — 
Extent  of  Lesion.  Fistula  in  front  of  the  uterus  large  enough  to  admit  the  index 
finger. — Cornjilicutions.  Vagina  narrowed  to  admit  only  a  probe  to  the  deptli  of  an 
inch  and  a  half ;  cul-de-sac  destroyed  ;  uterus  retroverted  and  bound  down  by 
adhesions. —  Treatment.  Vagina  opened  by  two  operations;  fistula  closed  by  one 
operation  and  6  sutures  transverse  to  the  axis  of  the  vagina  ;  removed  9th  day. — 
Duration  of  Treatment,  10  weeks  ;  Result,  cured. 

21  (lii.).     Admitted  Oct.  20,  1S63.     Age  22.     Age  at  marriage  20.     No.  of  child- 

ren 1. 
Historj.  In  labor  51  hours, :  ergot  and  forceps  ;  stillborn  ;  some  urine  lost  two 
days  after  delivery  ;  no  control  after  three  weeks,  when  a  slough  was  passed.  Deliv- 
ered three  months  before  admission. — Extent  of  Lesion.  Fistula  just  in  front  of 
the  cervix  ;  there  had  been  great  loss  of  tissue,  but  now  contracted  to  the  size  of 
No.  12  bougie  ;  cicatricial  edges. —  Complirations.  Vagina  shortened  and  partially 
occluded  by  bands  in  front  of  and  concealing  the  fistula. —  Treatment.  With  the 
edges  of  the  fistula,  one-third  of  an  inch  of  surrounding  tissue  was  removed ;  6 
sutures  used  ;  there  was  so  little  bleeding  after  finding  the  bands  that  a  plug  was 
not  needed  and  the  operation  Avas  done  at  the  same  time. — Duration  of  Treatment, 
7  weeks  ;  Result,  cured. 

22  (lix.).     Admitted^ov.  27,  1863.     Age  35.     Age  at  marriage  28.     No.  of  child- 

ren 4. 
History.  In  labor  102  hours  :  delivered  by  forceps  ;  stillborn  child,  under  the 
average  size  ;  bladder  not  emptied  ;  escape  of  urine  from  delivery.  Injured  four- 
teen months  before  admission. — Extent  of  Lesion.  Very  large  circular  slough  ; 
narrowing  of  vagina  ;  loss  of  part  of  urethra  ;  cicatricial  bands,  extending  from 
under  the  pubis  downward  and  backward  to  the  recto- vaginal  septum,  formed  two 
folds  beneath  which  was  a  small  ofjening  into  neck  of  bladder. —  Treatment.  Fis- 
tula closed  without  dividing  the  bands,  for  had  this  been  done,  incontinence  of 
urine  would  have  resulted,  as  the  neck  of  the  bladder  was  lost ;  6  sutures  used  ; 
removed  on  the  l-4th  day  ;  cured  by  one  operation. — Duration  of  Treatment,  8 
weeks  ;  Result,  cured. 

23  (xLii.).     ^cZmi«ec?  Dec.  18,  1863.     Age  25.     Age  at  marriage  23.     No.  of  child- 

ren 1. 
History.  In  labor  105  hours  :  forceps  ;  child  very  large  and  stillborn  ;  bladder 
not  emptied  ;  urine  escaped  4  days  after  delivery.  Injured  five  months  before 
admission. — Extent  of  Lesion.  Loss  of  the  left  half  of  the  base  of  the  bladder ; 
semicircular  opening  two  inches  long  and  one  wide. —  Treatment.  Fistula  closed 
by  one  operation  ;  10  sutures  ;  the  difficulty  was  in  passing  the  sutures  to  radiate 
from  a  common  centre,  so  that  two  different  arcs  of  a  circle  could  be  brought  to- 
gether without  puckering. — Duration  of  Treatment,  6  weeks  ;  Result,  cured. 

24  (xxxvii.).     Admitted  Jan.   28,  1864.     Age  40.     Age   at  marriage  28.     No.  of 

children  4. 
History.  In  labor  105  hours :  forceps  ;  child  large  and  stillborn ;  bladder 
frequently  emptied  ;  urine  escaped  from  time  of  delivery.  Injured  seven 
years  previous  to  admission. — Extent  of  Lesion.  Loss  of  the  whole  base  of  the 
bladder;  the  inner  face  of  the  left  ramus  divided. —  Treatment.  Fistula  closed 
by  three  progressive  operations  ;  it  was  necessary  to  dissect  up  the  tissues  freely 
to  free  the  edges. — Duration  of  Treatment,  3  months  ;  Result,  cured. 


682  CASES    OF    TESICO-VAGINAL    FISTULA 

25.  Admitted  Feb.  2,  1864.     Age  26.     Age  at  marriage  24.     No.  of  children  1. 

Eistorij.  In  labor  5  days  :  delivered  by  forceps  ;  bladder  emptied  naturally  ; 
admitted  ten  days  after  delivery. — Extent  of  Lemon.  An  opening  in  the  centre  of 
the  base  of  the  bladder  admitting  the  index  finger. — Complications.     Rectal  fistula. 

—  Treatment.  Fistula  closed  in  three  weeks  by  the  frequent  use  of  hot  water, 
vaginal  injections,  and  without  an  operation. — Duration  of  Treatment,  3  weeks  ; 
Result,  cured. 

26  (lxviii.).     Admitted 'P eh.  2,  l^iQA.    Age  27.    Age  at  marriage  19.     No.  of  child- 

dren  1. 
History.  In  labor  65  hours  :  delivered  by  efforts  of  nature ;  bladder  not  emp- 
tied until  24  hours  after  delivery  ;  urine  then  lost  for  several  weeks,  when  she 
regained  retentive  power  for  a  time.  Injured  two  years. — Extent  of  Lesion.  The 
opening  into  the  bladder  was  not  suspected  until  after  dividing  some  cicatricial 
bands,  when  the  tension  being  relieved  the  urine  continiied  to  escape  from  a  fis- 
tula behind  the  left  ramus,  admitting  a  No.  12  bougie. — Complications.  Eectal  fis- 
tula. Treatment.  Fistula  closed  without  difSculty  with  8  sutures  and  by  one 
operation. — Duration  of  Treatment,  6  weeks  ;   Result,  cured. 

27  (vii.).     Admitted  April  4,  1864.     Age  26.     Age  at  marriage  21.     No.  of  child- 

ren 3. 
History.  In  labor  37  hours  :  natural  delivery  ;  stillborn  ;  weighed  12  pounds  ; 
the  bladder  was  not  emptied  ;  injured  21  months  ;  urine  lost  after  the  14th  day. 
— Extent  of  Lesion.  A  sinus  from  the  bladder  entered  the  cervical  canal  above 
the  vaginal  junction,  from  a  laceration  of  the  cervix  through  the  anterior  lip,  in 
the  median  line,  which  had  united  from  above,  leaving  the  sinus  at  the  bottom  oi 
the  tear. — Treatment.  Reproduced,  with  a  pair  of  scissors,  the  original  condition, 
then  obliterated  the  tract  of  the  sinus  ;  surfaces  were  brought  together  by  5 
sutures  at  one  operation. — Duration  of  Treatment ,  4  weeks  ;  Result,  cured — Remarks. 
Had  been  operated  on  twice  before  admission,  and  with  benefit. 

28  (xvi.).  Admitted  April  10,  1864.     Age  27.     Age  at  marriage  24.     No.  of  child- 

ren 1. 
History.  In  labor  104  hours  :  natural  delivery  ;  very  large  child,  stillborn ; 
the  bladder  was  not  emptied  until  after  delivery  ;  began  to  lose  control  after  two 
weeks.  Injured  two  years. — Extent  of  Lesion.  Loss  of  two-thirds  of  the  base  of 
the  bladder  in  front  of  the  cervix,  with  the  posterior  lip  and  cul-de-sac  ;  fistula 
from  one  ramus  to  another,  with  receding  edges.  A  false  passage  had  been 
made  from  the  urethra  about  a  third  of  an  inch  in  front  of  the  fistula. —  Complica- 
tions. Angle  of  the  fistula  on  the  right  side  ;  the  surrounding  parts  were  a  mass 
of  cicatricial  tissue  ;    urethra  impervious,  with  a  false  ojjening  into  the  vagina. 

—  Treatment.  First  operation  was  to  open  the  urethra ;  a  week  after,  closed 
the  fistula  with  14  sutures  ;  successful ;  a  small  opening  afterwards  from  tension, 
which  was  closed  by  a  subsequent  operation. — Duration  of  Treatment,  9  weeks  ; 
Result,  cured. 

29  (xxii.).     Admitted  ATpril  27 ,  ISGA.    Age  33.    Age  at  marriage  27.     No.  of  child- 

ren 2  ;  of  miscarriages  1. 
History.  In  labor  70  hours  :  delivered  by  forceps  ;  child  stillborn  ;  10  pounds  ; 
the  bladder  was  not  emptied  until  by  catheter  before  applying  the  forceps  ;  urine 
escaped  a  week  after  delivery.  Injured  thirty-four  months. — Extent  of  Lesion. 
Anterior  lip  lost,  with  a  large  portion  of  the  bladder,  forming  a  transverse  fistula 
from  one  side  of  tlie  vagina  to  tlie  other ;  nature  attempted  to  close  the  fistula  by 
uniting  a  portion  of  its  anterior  edge  to  the  posterior  lip  of  the  uterus  and  vaginal 
wall  on  a  line  with  the  cervix  ;  in  this  line  two  openings  were  left,  one  small,  the 
other  admitting  the  finger. —  Treatment.  Nature  had  shut  the  mouth  of  the  uterus 
up  within  the  bladder,  and  this  effort  was  completed  ;  9  sutures  were  used  for  the 
larger  opening,  ami  3  for  the  smaller  one  ;  they  were  removed  on  the  8th  day. — 
Duration  of  Treaimeut,  5  weeks  ;  Result,  cured. 

30  (xiir.).     Admitted  May  24,  1804.     Age  24.     Age  at  marriage  22,     No.  of  child- 

ren 1. 
History.       In    labor    50    hours:    delivered    by    forceps;    large    child,   stillborn; 
l)ladder  emptied  regularly  ;  a  slougli  passed  on  the  19th  day  ;  loss  of  urine  after- 


RESULTING    FROxM    CniLDBIRTII.  683 

wards.  Injured  two  months. — Extent  of  Lesion.  A  slough  had  extended  from  the 
cervix  to  the  neck  of  tlie  bhadder ;  by  healing  from  both  ends,  the  listula  con- 
tracted to  a  circuLir  opening,  only  large  enough  to  admit  the  index  finger,  and  was 
situated  in  the  centre  of  tlie  base  of  the  bladder. —  Complications,  Laceration  of 
the  anterior  lip. —  Treatment.  Two  jMirallel  incisions  were  made  on  each  side  of 
the  fistula,  througli  the  cicatricial  tissue,  and  these  surfaces  were  united  by  7 
sutures  ;  removed  ou  the  9th  day. — Duration  of  Treatment,  8  weeks  ;  Result,  cured. 

31  (x.).     Admitted  June  3,  1864.     Age  40.     Age  at  marriage  26.     No.  of  child- 

ren 9. 
History.  Labor  42  hours  :  ergot,  forceps ;  large  stillborn  child  ;  bladder  not 
emptied;  urine  lost  from  delivery.  Injured  three  months. — Extent  of  Lesion. 
Lateral  laceration  into  the  bladder  through  the  cervix  on  the  right  side  ;  opening 
large  enough  to  admit  two  fingers. —  Treatment.  First  oijeration  not  entirely  suc- 
cessful ;  9  sutures  were  used  ;  readmitted,  and  by  second  operation  closed,  using 
9  sutures. — Duration  of  Treatment,  8  weeks  ;  Result,  cured. 

32  (xxx.).     Admitted  Sept.  16,  1864.     Age  36.     No.  of  children  1. 

Histori/.  Puerperal  convulsions  on  the  3d  day;  in  labor  96  hours:  forceps; 
stillborn  ;  unable  to  give  any  information  regarding  the  bladder  ;  escape  of  urine 
two  weeks  after  delivery.  Injured  eleven  months. — Extent  of  Lesion.  Loss  of  the 
upper  third  of  the  base  of  the  bladder  ;  by  cicatrization  and  shortening  of  the 
vagina,  the  opening  reduced  in  size  so  as  to  admit  the  point  of  a  large  sound. — 
Complications.  Great  extent  of  cicatricial  tissue. —  Treatment.  A  concave  incision 
was  made  in  healthy  tissue  half  an  inch  from  the  neck  of  the  bladder  and  around 
the  fistula ;  the  cicatricial  edges  were  removed  ;  closed  by  9  sutures. — Duration  of 
Treatment,  6  weeks  ;  Result,  cured. 

33  (xLi.).     Admitted  Oct.  10,  1864.     Age  46.     Age  at  m:arriage  21.     No.  of  child- 

ren 10. 
History.  In  last  labor  95  hours  :  ergot  ;  delivered  "  b^rhand  ;"  child  had  been 
dead  some  time  ;  bladder  not  emptied  for  83  hours  ;  loss  of  urine  from  delivery. 
Injured  four  years  and  a  half. — Extent  of  Lesion.  Loss  of  the  right  half  of  the  base  of 
the  bladder;  by  contraction,  the  vagina  was  shortened  and  the  fistula  reduced  to  less 
than  an  inch  in  size  and  hidden  at  the  bottom  of  two  deep  folds. —  Treatment. 
Edges  of  the  fistula  were  cicatricial ;  these  were  denuded  with  the  sides  of  the 
folds  and  brought  together  by  16  sutures. — Duration  of  Treatment,  5  weeks  ;  Result, 
cured. 

34  (xxxiii.).     Admitted   Oct.  11,  1864.     Age    31.     AgQ    at  marriage    21.     No.  of 

children  4. 
History.  Chloroform  ;  21  hours  in  labor  :  delivered  by  forceps  ;  child  16  pounds  ; 
stillborn  ;  bladder  was  emptied  ;  loss  of  urine  from  delivery  ;  confined  to  her 
bed  several  months.  Injured  41  months. — Extent  of  Lesion.  Loss  of  the  whole 
1)ase  of  the  bladder  ;  the  fistula  was  more  than  three  inches  in  length,  and  extended 
obliquely  to  the  right  across  the  axis  of  the  vagina,  from  contraction  of  bands  in 
the  posterior  cul-de-sac. — Complications.  The  mouth  of  each  iireter  was  in  the 
edge  of  the  fistula ;  uterus  immovable. — Treatment.  After  division  of  bands  in 
the  cul-de-sac,  the  fistula  was  closed  by  20  sutures  ;  successful  ;  twice  afterwards, 
by  traction,  openings  were  made  and  finally  closed. — Duration  of  Treatment,  18 
weeks ;  Result,  cured. — Remarks.  Had  been  operated  on  twice  previous  to 
admission. 

35  (xLiii.).     Admitted  Oct.  14,  1864.     Age  31.     AgQ  at  marriage  22.     No.  of  child- 

ren 2. 
History.  In  labor  90  hours  :  delivered  by  eflForts  of  nature  after  the  use  of 
ergot  ;  bladder  not  emptied :  urine  esca,ped  from  delivery  ;  legs  paralyzed  for 
several  weeks.  Injured  three  years  and  a  half. — Extent  of  Lesion.  The  left  half 
of  the  base  of  the  bladder  was  lost  by  sloughing,  with  the  neck  of  the  uterus  and 
posterior  cul-de-sac  ;  the  vagina  was  shortened  and  narrowed,  with  occlusion  of 
the  uterine  canal ;  uterus  atrophied. —  Treatment.  Fistula,  after  much  difiiculty, 
was  closed  by  19  sutures  ;  on  removing  the  sutures,  a  small  opening  was  made, 
which  closed  by  subsequent  operation  ;  another  small  opening  closed  by  contrac- 
tion.— Duration  of  Treatment,  12  weeks  ;  Result,  cured. 


684  CASES    OF    VESICO-VAGINAL    FISTULA 

36  (xxxix.).  Admitted  Oct.  17,  1864.  Age  27.  Age  at  marriage  25.  No.  of 
children  1. 
History.  In  labor  224  hours  :  delivered  by  forceps  ;  was  not  in  charge  of  a  phy- 
sician until  the  8th  day  ;  the  child  was  large  and  in  a  patrid  condition  ;  during 
labor  the  bladder  was  emptied,  but  "for  a  number  of  days  after"  the  urine  was 
retained,  and  suddenly  escaped  in  a  large  quantity.  Injured  seventeen  months 
before  admission. — Extent  of  Lesion.  Loss  of  the  whole  base -of  the  bladder,  the 
cervix  uteri,  and  cul-de-sac,  with  the  inverted  bladder  protruding  through  the 
fistula  in  the  midst  of  cicatricial  tissue  ;  this  tissue  was  chiefly  from  the  ramus  on 
the  rio-ht  side,  along  the  edge  of  the  fistula,  on  the  lateral  wall,  into  the  cul-de- 
sac,  binding  down  the  remains  of  the  cervix  uteri. —  Treatment.  The  cicatricial 
band  was  divided  in  several  places,  and  the  cervix  freed  from  adhesions  ;  the  glass 
plug  was  used ;  from  the  character  of  the  tissue  it  required  five  operations  before 
the  "opening  was  bridged  over, — Duration  of  Treatment,  9  months  ;  Result,  cured. 

37.     Admitted  Oct.  27,  1864.     Age  31.     Age  at  marriage  22.     No.  of  children  4. 

History.  In  labor  24  hours  :  delivered  by  forceps  ;  child  stillborn,  and  weighed 
16  pounds;  the  bladder  was  emptied  regularly. — Extent  of  Lesion.  Loss  of  the 
entire  base  of  the  bladder  and  cervix,  with  the  uterus  bound  down  by  adhesions. 
—  Treatment.  The  great  difficulty  was  in  freeing  the  edges  by  extensive  dissection ; 
the  fistula  was  closed  after  four  operations. — Duration  of  Treatment,  12  months  ; 
Result,  cured. 

88.     Admitted  Nov.  5,  1864.     Age  35.     Age  at  marriage  23.     No.  of  children  1. 

History.  In  labor  44  hours  :  version,  and  head  delivered  by  forceps  ;  the  bladder 
had  been  emptied. — Extent  of  Lesion.  Loss  of  the  base  of  the  bladder  and  urethra, 
with  the  sub-pubic  tissue ;  inner  face  of  both  rami  denuded. — Complications. 
"  Hour-glass"  constriction  of  the  vagina  from  a  circular  slough. —  Treatment.  Four 
operations  ;  Result,  not  improved. 

39  (liv.).     J.J/n8«ecZ  Nov.  5,  1864.     Age  29.     Age  at  marriage  27.     No.  of  child- 

ren 1. 
History.  In  labor  15  hours  :  ergot ;  forceps  ;  stillborn  ;  large  size  ;  the  bladder 
was  frequently  emptied ;  loss  of  urine  from  time  of  delivery  ;  confined  to  bed  two 
mouths. — Extent  of  Lesion.  The  vagina  was  almost  closed  throughout  its  length, 
with  loss  of  the  oul-de-sac  ;  vagina  opened  by  scissors,  laceration,  and  the  knife; 
the  fistula  was  found  situated  immediately  behind  the  left  ramus. — Complications. 
Contraction  of  the  vagina. —  Treatment.  Vagina  opened,  and  patient  returned  home 
wearing  a  glass  plug  ;  readmitted  ;  vagina  deepened  ;  6  months  after,  fistula  closed, 
small  opening  left,  closed  by  a  second  operation. — Duration  of  Treatment,  6  months  ; 
Result,  cured. 

40  (lvu.).     Admitted  ^ov.  10,  I'^QA.     Age  42.     Age  at  marriage  32.     No.  of  child- 

ren 6. 
History.  Chloroform  ;  in  labor  12  hours  :  breech  delivered  "  by  traction  ;"  child 
dead  ;  bladder  not  emptied  ;  urine  lost  two  weeks  after  delivery  ;  confined  to  bed 
two  months. — Extent  of  Lesion.  The  fistula  was  situated  behind  the  right  ramus, 
lessened  in  size  by  the  contraction  of  cicatricial  tissue,  and  the  vagina  shortened 
so  as  to  form  a  cystocele  ;  the  opening  was  large  enough  to  admit  the  index  finger, 
—  Treatment.  A  broad  oval  surface  was  removed  around  the  fistula,  so  as  to  extend 
to  the  right  of  the  cervix  ;  17  sutures  were  introduced,  and  the  fistula  cIosihI  on 
bringing  together  the  parts  for  the  removal  of  the  cystocele. — Duration  of  Treat- 
ment, 4  weeks  ;  Result,  cured. 

41  (i.).     Admitted 'Nov .  29,  1864.     Age  44.     Age  at  marriage  18.     No.  of  children 

15  ;  of  miscarriages  1. 
History.  .  In  labor  133  hours  :  child  removed  by  traction  ;  stillborn  ;  weighed 
14  pounds  ;  the  bladder  was  not  emptied  for  a  great  portion  of  the  time  ;  escaped 
on  the  9th  day  after  delivery. — Extent  of  Tjcsion.  An  antero-posterior  laceration  of 
the  cervix  uteri,  with  a  fistula  extending  in  the  median  line;  from  the  cervix  to 
tlie  neck  of  the  bladder. — Complicnilons.  Cicatricial  tissue  on  tlie  edges  and  join- 
ing vaginal  surface. —  Treatinr'nt.  Two  long  incisions  were  made  through  tlie  cica- 
tricial surface,  and  these  surfaces  were  brought  together  in  connection  with  the 


RESULTING    FROM    CIIILDBIRTII.  685 

laceration  through  the  cervix  ;  10  sutures  were  used. — Duration  of  Treatment,  10 
weeks;  Result,  cured. — lieinurks.  Stoue  removed  tVuiu  the  bladder  eighteen  months 
alter  operation. 

42  (lxv.).     .l(//«i/^ec/ Nov.  30,  1SG4.     Age  30.     Age  at  marriage  22.     No.  of  child- 

ren 2. 
Ilistorj.  In  labor  92  hours  :  delivered  with  forceps ;  bladder  not  emptied  for 
24  hours  before  delivery  ;  placenta  retained  three  days  ;  on  its  removal,  lost  con- 
trol of  the  urine;  contined  to  bed  for  two  months.  Injured  fifty  montlis  before 
admission. — Kxlent  of  Lesion.  Loss  of  the  whole  base  of  the  bladder,  the  cervix 
uteri,  and  laceration  in  the  median  line  almost  to  the  vesico-uterine  junction,  with 
destruction  of  the  neck  of  the  bladder  and  nearly  the  whole  urethra  ;  the  uterus 
was  iunnovable  and  drawn  to  the  right  &u\o.— Treatment.  After  eleven  operations 
the  fistula  was  bridged  over  ;  a  new  urethra  was  made  throughout,  and  after  three 
additional  operations  she  was  discharged,  with  voluntary  retentive  power. — Dura- 
tion oj  Treatment,  2  years  ;  Result,  cured. 

43  (xLvi.).     ^f/m/«eJDec.  2,  1864.     Age  19.     Age  at  marriage  18.     No,  of  child- 

ren 1. 
Historj.  In  labor  81  hours  :  ergot ;  bladder  not  emptied  ;  large  child  ;  still- 
born;  urine  escaped  from  time  of  delivery.  Injured  fifteen  weeks. — Extent  of 
Lesion.  Two  fistulse,  one  near  the  neck  of  the  bladder  to  the  right,  and  the  other 
near  the  cervix  on  the  same  side ;  there  had  been  lateral  laceration  of  the  cervix, 
with  sloughing. —  Complications.  Vagina  shortened  by  bands  from  the  lower  fistula 
across  to  the  left  side  of  the  vagina  around  into  the  cul-de-sac  to  the  upper  open- 
ing.—  Treatment.  The  band  had  to  be  extensively  divided,  and  each  fistula  was 
closed  by  a  single  operation. — Duration  of  Treatment,  4  months  ;  Result,  cured. 

44  (lxiii.).     Admitted  Bee.  8,  1864.     Age  23.     No.  of  children  1. 

History.  In  labor  98  hours:  ergot;  breech  presentation;  "instrumental" 
delivery  ;  child  stillborn  ;  12  pounds  ;  bladder  not  emptied  until  just  before 
delivery  ;  urine  began  to  escape  on  the  second  day  afterwards.  Injured  about 
four  years. — Extent  of  Lesion.  There  had  been  a  slough  under  the  arch  of  the 
pubes  entirely  across  the  vagina,  which  destroyed  the  neck  of  the  bladder  ;  after 
cicatrization  an  opening  was  left  at  the  neck  of  the  bladder  only  large  enough  to 
admit  a  No.  12  bougie  ;  a  semilunar  shaped  band  extended  from  each  side  of  the 
fistula  down  on  to  the  posterior  wall,  so  as  to  contract  the  vagina. —  Complications. 
Occlusion  of  the  urethra. —  Treatment.  The  bands  were  cut  and  a  new  urethra 
made  by  puncture  ;  a  tube  was  retained  in  the  false  passage  some  ten  days,  until 
healed  ;  a  month  after,  the  fistula  was  closed  by  5  stures. — Duration  of  Treatment, 
2  months  ;  Result,  cured. 

45  (xxxv.).     Admitted  Dec.  21,  1864.   Age  32.   Age  at  marriage  25.     No.  of  child- 

ren 4. 
History.  Puerperal  convulsions  :  delivered  by  forceps,  after  a  labor  of  51  hours  ; 
stillborn  ;  not  known  if  the  bladder  was  emptied  ;  urine  did  not  escape  until  3 
weeks  after  delivery:  confined  to  the  house  for  six  months  after.  Injured  five 
years  previous  to  admission. — Extent  of  Lesion.  Loss  of  the  entire  base  and  neck 
of  the  bladder  ;  at  each  angle  the  edges  sloped  inward,  so  that  opening  was  but 
an  inch  and  a  quarter  long  by  an  inch  in  width  ;  the  tissue  in  front  of  the  fistula 
was  thrown  into  numerous  folds  like  a  cystocele  ;  vagina  shortened,  and  this  mass 
hid  the  anterior  lip  of  the  fistula. — Complications.  Extensive  cicatricial  bands 
from  in  front  of  the  fistula  to  the  urethral  outlet,  backward  along  the  angles  to 
the  lateral  walls  into  the  cul-de-sac. —  Treatment.  The  fistula  was  closed  by  bridg- 
ing over  the  opening  with  the  cystocele,  thus  turning  the  vaginal  tissue  into  the 
bladder  ;  by  this  means  traction  was  not  made  on  the  shortened  urethra. — Dura- 
tion of  Treatment,  4  weeks  ;  Result,  cured. 

46  (Lxvir.).     Admitted  Feb.  12,  1865.     Age   23.     Age   at  marriage   21.     No.  of 

children  1. 

Hisforij.     Time  of  labor  and  condition  of  the  bladder  imknown  ;  delivered  by 

craniotomy  a  year  before  first  examination. — Extent  of  Lesion.     Loss  of  the  greater 

portion  of  the  neck  and  base  of  the  bladder,  but  the  vagina  had  become  shortened 

by  contraction,  so  that  the  sides  of  the  fistula  lay  in  contact  at  the  bottom  of  a 


686  CASES    OF    VESICO-VAGINAL    FISTULA 

deep  sulcus. — Complications.  A  recto-vaginal  fistula. —  Treatment.  A  cicatricial 
band  crossed  the  remains  of  the  urethra  and  ran  backward  on  to  the  posterior 
wall ;  this  gave  retentive  power  after  the  fistula  had  been  closed  with  9  sutures  ; 
the  line  of  union  extended  from  one  ramus  to  the  other. — Duration  of  Treatment, 
6  weeks  ;  Result,  cured. 

47  (lx.),     ^f/m/«ec?  April  22,  1865.     Age  28.     Age  at  marriage  18.     No.  of  child- 

ren 1 ;  of  miscarriages  1. 
History.  In  labor  71  hours  :  delivered  by  traction  ;  bladder  had  been  emptied 
regularly  ;  urine  began  to  escape  from  delivery. — Extent  of  Lesion.  A  fistula  three 
inches  in  length  extended  through  the  neck  of  the  bladder  across  from  ramus  to 
ramus  ;  the  vaginal  outlet  had  been  encircled  by  a  slough  ;  this  drew  the  corners 
up  behind  the  bones,  while  only  the  urethra  had  been  lacerated. —  Treatment. 
The  opening  was  at  the  bottom  of  a  deep  sulcus  ;  the  only  difficulty  was  in  ajjproxi- 
mating  the  two  sections  of  the  urethra ;  12  sutures  were  used. — Duration  of  Treat- 
ment, 5  weeks  ;  Result,  cured. 

48  (xxiii.)     Admitted 'iA&j  25,  l^QZ.     Age  44.     Age  at  marriage  22.     No.  of  child- 

ren 3. 
History.  Natural  labor  of  26  hours  :  the  bladder  was  not  emptied  ;  urine  began 
to  escape  on  the  3d  day. — Extent  of  Lesion.  Loss  of  the  cervix  uteri,  with  the 
whole  base  of  the  bladder  ;  by  bands  in  the  cul-de-sac  the  fistula,  which  was 
three  inches  in  length,  was  drawn  into  a  crescentic  form,  with  its  cornua  posterior 
to  the  cervix  uteri. —  Treatment.  Bands  were  freely  divided  and  tissues  dissected 
up  from  behind  the  bone  ;  operation  on  the  knees  and  elbows,  very  difficult ;  14 
sutures  used. — Duration  of  Treatment,  4  weeks  ;  Result,  cured. 

49.  Admitted  Sept.  30,  1865.  Age  34.  Age  at  marriage  23.  No.  of  children  1  ; 
of  miscarriages  2. 
History.  In  labor  26  hours  :  child  very  large  ;  bladder  not  emptied. — Extent  of 
Lesion.  The  entire  base  of  the  bladder  lost;  vagina  contracted  by  cicatricial 
bands. — Treatment.  Four  operations. — Duration  of  Treatment,  5  years  ;  Result, 
cured. 

50  (viii.).  Admitted  Oct.  2,  1865.  Aga  20.  Age  at  marriage  19.  No.  of  child- 
ren 1. 
History.  In  labor  45  hours  :  delivered  by  craniotomy  ;  bladder  not  emptied  the 
last  24  hours  ;  loss  of  urine  from  the  3d  day. — Extent  of  Lesion.  Anterior  lacera- 
tion of  the  cervix,  which,  becoming  partially  closed,  left  a  sinus  communicating  with 
the  uterine  canal  from  a  large  fistula  in  front. —  Treatment.  With  a  pair  of  scissors 
the  original  condition  was  produced  ;  the  tract  of  the  sinus  removed  and  the 
edges  of  the  opening  closed  by  8  sutures. — Duration  of  Treatment,  4  weeks  ;  Result, 
cured. 

51.  Admitted  Oct.  3,  1865.     Age  31.     Age  at  marriage  20.     No.  of  children  6. 
History.     In  labor  90  hours  :  delivered  by  craniotomy  ;  bladder  was   regularly 

emptied. — Extent  of  Lesion.  The  base  of  the  bladder  was  lost,  vagina  contracted, 
and  by  this  means  the  cervix  was  turned  into  tlie  bladder. —  Treatment.  2  opera- 
tions.— Duration  of  Treatment,  5  months  ;  Result,  improved. — Remarks.  Did  not 
return  for  a  final  operation,  and  may  have  been  cured. 

52.  Admitted  Oct.  3,  1865.     Age  30.     Age  at  marriage  28.     No.  of  children  2. 
History.     In  labor  19  hours  :  delivered  with  forceps  ;  stillborn  ;  bladder  emptied. 

— Extent  of  Lesion.  Fistula  one  inch  in  diameter  just  in  front  of  the  neck  of  the 
bladder;  there  had  been  great  loss  of  tissue  with  contraction. —  Treatment.  2 
operations;  one  only  for  closing  the  fistula. — Duration  of  Treatment,  "d  weeks; 
Result,  cured. 

53  (xxvi.).  Admitted  Oct.  4,  18G5.  Age  30.  Age  at  marriage  27.  No.  of  child- 
ren 2. 
History.  Delivered  by  craniotomy  :  in  labor  49  hours  ;  the  blndder  was  not 
emptied  ;  urine  escaped  from  delivery  ;  confined  to  bed  three  months.  Injured 
eigliteen  months. — Extent  of  Lesion.  A  slough  had  extended  in  the  median  line, 
from  the  cervix  to  the  neck  of  the  bladder,  but  by  contraction  of  cicatricial  bands 


RESULTING  FROM  CHILDBIRTH.  G87 

the  opening  became  a  transverse  one  in  front  of  the  cervix. — Complications.  Vagina 
sliortened  by  contraction. —  Treatment.  The  edges  were  secured  by  14  sutures,  as 
tliey  lay  nearly  in  contact. — Duration  of  Treatment,  4  weeks ;  Result,  cured. 

54  (hi.).     Admitted  Oct.  4,  1865.     Age  37.     Age  at  marriage  19.     No.  of  children 

5  ;  of  miscarriages  1. 
History.  Labor  45  hours'  duration  :  delivered  by  forceps  ;  child  stillborn  and  of 
a  large  size  ;  bladder  was  not  emptied,  although  the  attempt  had  been  made  ;  loss 
of  urine  from  delivery.  Injured  six  months. — Ejclent  of  Lesion.  There  had  been 
laceration  of  the  cervix  through  the  anterior  lip  into  the  base  of  the  bladder, 
leaving  a  fistula  in  the  median  line  one  inch  in  diameter. — Complications.  Uterus 
retroverted. —  Treatment.  The  opening  was  irregular  in  shajje  and  difficult  on  this 
account  to  be  brought  together ;  9  sutures  were  used  ;  removed  on  the  11th  day. 
— Duration  of  Treatment,  4  weeks  ;  Result,  cured. 

55  (iv.).     Admitted  Oct.  5,  1865.     Age  26.     No.  of  children  1. 

History.  In  labor  72  hours  :  natural  delivery  ;  bladder  emptied  ;  child  still- 
born and  of  a  large  size.  Injured  about  seven  years. — Extent  of  Lesion.  A  small 
circular  opening,  an  eighth  of  an  inch  in  diameter,  in  front  of  the  cervix,  caused 
by  a  laceration  through  the  anterior  lip. —  Treatment.  Cut  through  the  cervix  to 
produce  the  original  condition,  then  united  all  by  9  sutures. — Duration  of  Treat- 
ment, 7  weeks  ;  Result,  cured. 

56.  .4f/m(V?ef/ Jan.  23,  1866.     Age  24.     Age  at  marriage  22.     No.  of  children  1. 

History.  In  labor  4  days,  and  delivered  by  forceps  ;  child  stillborn  ;  no  informa- 
tion given  in  relation  to  the  bladder. — Extent  of  Lesion.  Fistula  in  the  median 
line  and  centre  of  the  base  of  the  bladder,  half  an  inch  in  diameter. —  Complica- 
tions. Recto-vaginal  fistula. —  Treatment.  One  operation  ;  8  sutures  used  and 
removed  on  the  8th  day. — Duration  of  Treatment,  7  weeks ;  Result,  cured. 

57  (XL.).     ^(//ni«ec?  Feb.  21,  1866.     Age  20.     Age  at  marriage  17.     No.  of  child- 

ren 1. 
History.  In  labor  24  hours  :  natural  delivery  ;  child  14  pounds  ;  stillborn  ;  on 
the  3d  day  the  urine  began  to  escape.  Injured  eleven  months. — Extent  of  Lesion. 
Loss  of  nearly  the  whole  base  of  the  bladder,  a  portion  of  the  neck  of  the  uterus, 
and  the  cul-de-sac  ;  the  fistula  crescentic  in  shape,  and  the  vagina  shortened  by 
contraction  to  an  inch  and  a  half,  from  sloughing. — Treatment.  After  a  prepara- 
tory operation  for  enlarging  the  vagina  and  dividing  the  bands,  the  fistula  was 
closed  by  two  operations,  using  16  sutures  at  one  time,  and  11  at  the  other. — 
Duration  of  Treatment,  17  weeks  ;  Result,  cured. — Remarks.  Had  been  operated  on 
previous  to  admission. 

58  (xxxviii.).     Admitted  April  3,  1866.     Age  27.     Age  at  marriage  25.     No.  of 

children  1. 
History.  In  labor  58  hours  :  delivered  by  forceps  ;  stillborn  ;  5  weeks  previous 
to  admission  ;  no  information  in  regard  to  emptying  the  bladder  ;  urine  began 
to  escape  ou  the  2d  day. — Extent  of  Lesion.  A  fistula  involving  the  loss  of  the 
whole  base  of  the  bladder,  with  the  face  of  each  ramus  nearly  denuded  ;  the 
inverted  bladder,  with  a  portion  of  the  intestines,  frequently  became  partially 
strangulated  by  protruding  through  the  fistula. —  Treatment.  The  bands  were 
freely  divided  and  the  edge  of  the  fistula  dissected  off  from  the  inner  face  of  the 
right  ramus  ;  the  edges  were  then  closed,  from  the  left  ramus  to  the  right  of  the 
cervix,  by  11  sutures. — Duration  of  Treatment,  8  weeks  ;  Result,  cured. 

59  (xxix.).     Admitted  Sept.   26,   1866.     Age   30.     Age  at  marriage   26.     No.  of 

children  3. 
History.  Delivered  by  forceps  :  30  hours  in  labor  ;  7  days  after  the  birth  of  her 
child  the  urine  escaped  by  a  sudden  gush,  while  walking  about  her  room.  Injured 
three  months. — Extent  of  Lesion.  Loss  of  the  upper  half  of  the  base  of  the  bladder 
with  a  lateral  laceration  of  the  cervix  by  a  previous  labor  ;  the  fistula  was  cres- 
centic in  shape,  with  its  cornua  extending  into  the  cul-de-sac,  and  the  anterior  lip 
of  the  uterus  formed  its  posterior  boundary. —  Treatment.  The  bands  were  divided 
so  that  the  fistula  became  a  transverse  one,  into  which  three  fingers  could  be 
passed  ;  closed  by  14  sutures,  which  were  removed  in  2  weeks. — Duration  of  Treat- 
ment, 6  weeks  ;  Result,  cured. 


688  CASES    OF    VESICO-VAGINAL    FISTULA 

60  (xvii.).     Admitted  Sept.  27,  1866.     Age  29.     Age  at  marriage  19.     No.  of  cliild- 

ren  6. 
History.  Labor  terminated  naturally  in  48  hours  ;  nothing  of  note  during  its 
progress  ;  2  days  after,  the  urine  began  to  escape. — Extent  of  Lesion.  Transverse 
fistula  in  front  of  the  cervix,  which  had  sloughed  away  ;  by  bands  extending  into 
the  cul-de-sac,  the  vaginal  tissue  in  front  of  the  cervix  was  drawn  into  a  fold  so 
as  to  hide  the  opening  into  the  bladder. —  Treatment.  The  fold  was  freed,  so  as  to 
bring  the  fistula  into  view  ;  its  edges  were  very  thin,  so  that  the  vaginal  tissue 
was  also  denuded  ;  closed  by  10  sutures  ;  removed  on  the  10th  day. — Duration  of 
Treatment,  4  weeks  ;  Result,  cured. 

61  (XIX.).     Admitted  Oct.  1,  1866.     Age  28.     Age  at  marriage  19.     No.  of  child- 

ren 5. 
History.  In  labor  48  hours  :  delivered  by  forceps  ;  2  weeks  afterwards  the 
urine  began  to  escape  ;  made  a  tedious  recovery. — Extent  of  Lesion.  Sloughing  of 
the  anterior  lip  and  a  portion  of  the  base  of  the  bladder,  in  front  of  the  cervix, 
took  place;  by  shortening  of  the  vagina,  its  anterior  wall  became  doubled  en 
itself,  so  as  to  form  a  fold  which  hid  the  fistula. —  Complications.  Laceration  of  the 
posterior  lip  backwards,  with  subsequent  pelvic  cellulitis  and  retroversion  of  the 
uterus. —  Treatment.  The  operation  was  a  very  difficult  one,  as  the  fistula  could  not 
be  brought  into  view  ;  closed  chiefly  by  the  sense  of  touch  ;  occupied  two  hours. — 
,Duration  of  Treatment,  10  weeks  ;  Result,  cured. 

62.  Admitted  Oct.  17,  1866.     Age  24.     kge  at  marriage  18.     No.  of  children  4. 
History.     In  last  labor  30  hours  :  natural  delivery  ;  no  further  particulars  given. 

— Extent  of  Lesion.  Two-thirds  of  the  lower  portion  of  the  base  of  the  bladder 
was  lost,  leaving  a  transverse  fistula  from  ramus  to  ramus. —  Treatment.  4  opera- 
tions.— Duration  of  Treatment,  11  weeks  ;  Result,  cured. 

63.  Admitted  Nov.  19,  1866.     Age  30.     Age  at  marriage  29.     No.  of  children  1. 
History.     In  natural  labor  48  hours  ;  no  further  particulars  given. — Extent  of 

Lesion.  Originally  had  lost  the  whole  base  of  the  bladder,  but  from  firm  traction 
of  cicatricial  bands  opening  became  oblique  and  was  one  inch  and  a  half  in  length 
and  an  inch  wide. — Complications.  Urethra  occluded. —  Treatment.  5  operations  ; 
one  for  division  of  bands,  one  to  open  the  urethra,  and  three  to  close  the  fistula. 
— Duration  of  Treatment,  1  year  ;  Result,  improved. — Remarks.  A  small  opening 
left ;  she  did  not  return,  and  it  was  doubtless  closed  by  some  one  else. 

64  (v.).     Admitted  Nov.  26,  1866.     Age  36.     Age  at  marriage  26.     No.  of  child- 

ren 4. 
History.  Injured  in  the  last  labor,  5  weeks  previous  to  admission  ;  48  hours  in 
labor  and  delivered  by  "  traction  ;"  stillborn  ;  loss  of  urine  from  time  of  delivery. 
— Extent  of  Lesion.  A  fistula  in  the  median  line  extending  an  inch  and  a  quarter 
from  the  cervix  towards  the  neck  of  the  bladder,  and  had  resulted  from  a  lacera- 
tion of  the  anterior  lip  of  the  cervix  ;  the  fissure  was  deeper  in  the  uterine  canal 
than  on  aline  with  the  opening  through  the  vaginal  septum. —  Treatment.  First 
operation  successful ;  on  the  day  after  removal  of  sutures  jumped  out  of  bed  from 
fright,  and  the  urine  was  found  to  escape  from  the  os  uteri ;  reproduced  the  con- 
dition at  the  time  of  laceration,  with  a  successful  result. — Duration  of  Treatment, 
13  weeks  ;  Result,  cured. 

65  (l.).     Admitted  Jan.  19,  1867.     Age  36.     Age  at  marriage  19.     No.  of  child- 

ren 1. 
lEstory.  In  labor  48  hours,  and  delivered  by  forceps  :  child  stillborn  ;  no  recol- 
lection in  regard  to  emptyijig  the  bladder  ;  the  urine  began  to  escape  at  the  end 
of  first  week.  Injured  fifteen  years. — Extent  of  Lesion.  The  whole  base  of  the 
bladder  was  found  to  have  been  lost  and  the  cul-de-sac  and  the  vagina  shortened 
to  an  inch  and  a  lialf  in  deptli. —  Complications.  The  vaginal  outlet  contracted  by 
a  slough  behind  tlie  perineum  so  that  the  finger  could  not  be  introduced. —  Treat- 
ment. The  vagina  was  opened  to  the  depth  of  three  inches  and  the  fistula  closed; 
shortly  after  the  sutures  had  been  removed,  an  opening  was  found  behind  the 
right  ramus  ;  l.'J  sutures  used  at  first  and  5  afterwards. — Duration  of  Treatment,  12 
weeks  ;  Result,  cured. 


RESULTINU    FROM    CIIILDDIRTII.  G89 

66.  Admitted  Jan.  24,  1SG7. 

Illstori/.  No  record. — Extent  of  Lesion.  A  fistula  admitting  the  finger  situated 
in  front  of  the  cervix  and  caused  by  an  anterior  Laceration. —  Treatment.  1  ope- 
ration ;  6  sutures  ;  removed  12th  day. — Duration  of  Ireatment,  5  weeks  ;  Result, 
cured. 

67  (lxi.).     Admitted  Feh.  4,  18G7.     Age  38.     Age  at  marriage  27.     No.  of  child- 

r(;n  2. 
History.  In  labor  G2  hours  :  delivered  by  forceps  ;  stillborn  ;  the  bladder  was 
not  emptied  ;  urine  escaped  from  time  of  delivery. — Extent  of  Lesion.  The  whole 
base  of  the  bladder  lost,  but  became  greatly  reduced  in  size  by  opening  contrac- 
tion.— Complications.  Cicatricial  tissue  shortening  tlie  vagina. —  Treatment.  2  ope- 
rations ;  the  first  with  10  sutures  failed  from  traction  ;  band  divided  ;  second  ope- 
ration successful,  with  9  sutures. — Duration  of  Tretitment,  10  weeks  ;  Result,  cured. 
— Remarks.  Fistula  had  been  closed  before  admission,  but  opened  from  traction  of 
bands. 

68  (xxiv.).     Admitted  March  5,  18G7.     Age   38.     Age  at   marriage    18.     No.  of 

children  5. 
History.  Natural  labor  56  hours  :  bladder  had  been  frequently  emptied  ;  urine 
began  to  escape  on  the  9th  day. — Extent  of  Lesion.  Loss  of  the  anterior  lip  of  the 
cervix  and  upper  third  of  the  l)ase  of  the  bladder  ;  the  vaginal  tissue  was  drawn 
backward  like  a  hood,  so  as  to  hide  the  fistula. —  Treatment.  The  fistula  was 
closed,  but  no  union  took  place,  as  its  edges  were  cicatricial  ;  second  operation 
successful  by  cutting  out  the  surrounding  tissue,  and  bringing  together  healthy 
surfaces. — Duration  of'  Treatment,  7  weeks  ;  Result,  cured. 

69  (xLix.).     Admitted  A-pvil  5,  1S61.     Age  34.     Age  at  marriage  32.     No.  of  child- 

ren 1. 
nistory.  No  labor  pains  :  delivered  by  forceps  six  days  after  rupture  of  the 
membranes  ;  the  bladder  was  not  emptied,  although  the  attemi^t  was  made  ;  loss 
of  urine  from  delivery  ;  confined  to  bed  4  months  when  she  was  admitted  to  the 
Hospital. — Extent  of  Lesion.  The  vagina  was  narrowed  at  the  depth  of  an  inch 
and  a  half,  a  transverse  fistula  beyond,  with  perfect  occlusion  of  the  canal  at  the 
posterior  edge  of  the  opening  ;  the  vagina  was  opened  for  over  three  inches  in 
depth  without  detecting  the  position  of  the  uterus. —  Treatment.  The  fistula  into 
the  bladder  was  closed  after  two  operations,  by  bringing  together  the  tissue  along 
the  axis  of  the  vagina  in  two  folds  and  shutting  up  the  fistula  at  the  bottom  of  a 
pouch. — Duration  of  Treatment,  23  weeks  ;  Result,  cured. 

70  (xxv.).     Admitted  K^yW  \2,  l^Ql .     Age  27.     Age  at  marriage  23.     No.  of  child- 

ren 3. 
History.  In  labor  46  hours :  delivered  by  forceps  ;  stillborn ;  bladder  was 
emptied  ;  loss  of  urine  2  weeks  after  delivery.  Injured  ten  months  before  admis- 
sion.— Extent  of  Lesion.  Loss  of  the  anterior  lip  of  the  cervix  and  upper  portion 
of  the  base  of  tlie  bladder  ;  by  contraction,  the  vaginal  tissue  was  drawn  laterally 
into  two  folds  over  the  cervix  and  fistula,  and  these  extended  in  the  long  axis  of 
the  canal,  from  the  cul-de-sac  nearly  to  the  neck  of  the  bladder. —  Treatment. 
These  bands  were  dissected  off  from  the  posterior  lip,  so  that  the  fistula  was 
brought  into  view  and  easily  closed  by  9  sutures  ;  removed  the  11th  day. — Dura- 
tion of  Treatment,  4  weeks  ;  Result,  cured. 

71  (lxii.).     Adjniited  Aiwil  2T ,  1867 .     Age  18.     Age  at  marriage  16.     No.  of  child- 

ren 1. 
History.  The  head  was  born  at  the  end  of  74  hours  :  pains  then  ceased  ;  body 
delivered  15  hours  after  by  traction  ;  stillborn  ;  tlie  bladder  liad  not  been  emptied 
for  48  houi-s  previous  to  delivery ;  4  days  after,  it  began  to  escape. — Extent  of 
fjcsion.  The  urethra  was  lacera'ted  entirely  through,  half  an  inch  from  the  meatus  ; 
the  distal  portion  of  the  canal  was  so  dilated  that  a  large  portion  of  the  mucous 
membrane  protruded. —  Treatment.  The  difficulties  of  the  operation  consisted  in 
passing  the  sutures  so  as  to  bring  perfectly  into  apposition  the  two  sections  of  the 
canal,  of  diiferent  diameters  ;  one  operation  successful. — Duration  of  Treatment,  5 
weeks  ;  Result,  cured. 

44 


690  CASES    OF    VESICO-VAGIXAL    FISTULA 

72.  Admitted  Oct.  16,  1867.     Age  40.     No.  of  children  1. 

History.  Was  delivered  bj  forceps  of  a  living  child  one  year  after  marriage ; 
urine  was  lost  from  time  of  delivery  ;  was  confined  to  bed  for  six  months. — Extent 
of  Lesion.  Anterior  lip  and  base  of  the  bladder  lacerated  down  to  the  left  ramus  ; 
a  portion  of  the  cervix  had  sloughed  ;  by  contraction,  the  fistula  and  remains  of 
the  cervix  were  left  at  the  bottom  of  a  deep  sulcus  ;  it  was  with  great  ditficulty 
that  the  cervix  could  be  brought  into  view. — Complications.  Partial  atresia  of  the 
vagina. —  Treatment.  3  operations  :  one  to  divide  bands  ;  first  operation  closed  the 
fistula  by  following  the  crest  of  the  fold,  thus  covering  over  the  os  in  communi- 
cation with  the  bladder  ;  small  opening  closed  by  second  operation  ;  not  entirely 
successful. — Duration  of  Treatment,  8  months  ;  Result,  improved. — Remarks.  An 
opening  left  admitting  a  probe  ;  never  returned  to  have  this  closed,  as  it  was  done 
at  home. 

73.  Admitted  Oct.  20,  1867.     Age  34.     Age  at  marriage  32.     No.  of  children  1, 
History.     In  labor  48  hours  :    forceps  ;  bladder  not  emptied. — Extent  of  Lesion. 

—Fistula  at  the  neck  of  the  bladder  one  inch  in  diameter,  and  extended  across 
the  vagina. —  Treatment.    Closed  by  two  operations. — Duration  of  Treatment,  8  weeks  ; 

Result,  cured. 

74.  Admitted  Nov.  5,  1867.     Age  43.     Age  at  marriage  14.     No.  of  children  13; 
of  miscarriages  1. 

History.  With  the  eleventh  child  labor  lasted  three  days  :  forceps  ;  child  weigh- 
ing 14  pounds  ;  bladder  emptied  several  times  ;  loss  of  urine  from  3d  day  after 
delivery. — Extent  of  Lesion.  A  laceration  along  the  right  side  of  the  vagina  from 
the  cervix  to  the  right  ramus  ;  somewhat  crescentic  in  shape  ;  the  edge  of  the  fis- 
tula behind  the  bone  had  a  sloping  surface,  while  that  above  was  abrupt ;  this 
made  the  opening  into  the  bladder  much  smaller  than  at  the  beginning. —  Treat- 
ment. First  operation  used  16  sutures ;  small  opening  left  behind  the  ramus  ; 
second  operation  on  the  knees  and  elbows  ;  freed  the  parts  from  the  bone  ;  7 
sutures  ;  successful. — Duration  of  Treatment,  4  months ;  Result,  cured. 

75.  Admitted  Nov.  17,  1867.     Age  37.     No.  of  children  1, 

History.  In  labor  48  hours  :  delivery  by  forceps. — Extent  of  Lesion.  Fistula  in 
front  of  the  cervix  admitting  the  index  finger ;  the  result  of  laceration  through 
the  anterior  lip. — Complications.  Mania  after  confinement. —  Treatment.  2  opera- 
tions ;  unable  to  control  the  patient. — Duration  of  Treatment,  8  weeks  ;  Result,  not 
improved. 

76  (xxxi.).  Admitted 'Nov.  28,  1867.  Age  37.  Age  at  marriage  28.  No.  of  child- 
ren 5  ;  of  miscarriages  1. 
History.  Delivered  by  version  after  a  labor  of  8|-  hours  ;  child  stillborn  ;  on  the 
day  after  delivery  the  urine  began  to  escape. — Extent  of  Lesion.  The  vagina  was 
unusually  deep  ;  found  no  cervix,  but  two  openings  in  the  median  line,  high  up 
in  the  vagina,  which  led  into  the  bladder,  witli  a  septum  between  them  about  half 
an  inch  in  width  ;  this  septum  was  divided,  when  it  was  ascertained  that  the  fis- 
tula was  situated  in  front  of  the  remains  of  the  cervix  ;  the  edges  of  the  opening  were 
cicatricial  and  the  loss  of  tissue  had  been  extensive. —  Complications.  The  uterus 
was  retroverted  and  fixed. ^ — Treatment.  From  the  neck  of  the  bladder  to  the  cul- 
de-sac  a  denuded  line  extended  in  the  form  of  an  ellipsis  ;  then  tlie  intervening 
tissue  was  removed  so  as  to  leave  no  pouch  ;  these  surfaces  were  brought  together 
by  17  sutures,  making  a  line  of  three  inches. — Duration  of  Treatment,  6  weeks  ; 
Result,  cured. — Remarks.     Had  been  operated  on  9  times  before  admission. 

77.  Admitted'Sov.  28,  18G7.     Age  37.     Age  at  marriage  32.     No.  of  children  3. 

History.  In  the  first  labor  3  days,  witliout  pain  :  delivered  by  forceps  of  a  still- 
born child  ;  chloroform  ;  did  not  know  when  tlie  urine  began  to  escape  ;  passed  a 
large  stone  from  the  bladder  a  week  after  d(divery  ;  several  months  getting  well ; 
had  two  stillborn  children  since.  Injured  four  years. — Extent  of  Lesion.  The 
whole  base  of  the  bladder  was  lost,  from  tlie  cervix  to  the  urethra ;  behind  the 
left  ramus  the  bone  was  d(!nuded. —  Treatment.  First  operation  all  was  closed  but 
the  angle  behind  the  ramus;  this  was  left;  done  on  the  knees  and  elbows;  1.5 
sutures  used  ;    opening  behind  the  ramus  dissected  olf  and  closed  with  7  suturea 


RESULTING-    FROM    CIIILDBIRTH.  G91 

afterwards  ;  2  operations  to  close  small  openings  made  by  traction  ;  after  the  last 
operation  there  remained  a  pin-hole,  which  closed  by  contraction. — Duration  of 
IVeatinent,  18  mouths  ;  liesult,  cured. 

78.  Admitted  Dec.  20,  1867.     Age  29.     Age  at  marriage  25.     No.  of  children  1  ;  of 
miscarriages  2. 

Ilistori/.  Was  in  labor  180  hours  :  several  days  without  pain  after  rupture  of 
the  membranes  ;  delivered  by  hand  ;  stillborn  ;  could  give  no  information  re<'-ard- 
ing  the  bladder  ;  urine  began  to  escape  two  weeks  after  delivery  ;  confined  to  bed 
two  mouths  ;  two  miscarriages  since.  Extent  of  Lesion.  There  had  been  "Teat  loss 
of  tissue,  but  by  contraction  the  opening  was  reduced  in  size  to  admit  the  index 
finger,  and  was  situated  in  the  centre  of  the  base  of  the  bladder. —  Complications. 
Cicatricial  tissue. —  Treatment.  It  was  necessary  to  remove  so  much  of  the  sur- 
rounding tissue  with  the  edges  of  the  fistula  that  the  opening  was  a  very  large 
one  ;  closed  by  9  sutures. — Duration  of  'Treatment,  4  weeks  ;  liesult,  cured. 

79.  Admitted  Jan.  7,  1868.     Age  25.     Age  at  marriage  19.     No.  of  children  2. 
Historij.     In  labor  78  hours  :    delivered   by  forceps  ;    escape  of  urine  two  days 

after  delivery. — Extent  of  Lesion.  Loss  of  the  base  of  the  bladder,  the  cervix,  and 
cul-de-sac ;  vagina  shortened  to  one  inch  in  depth  ;  a  fistula  remained,  extending 
from  one  ramus  to  the  other,  with  its  edges  lying  in  contact ;  but  little  tissue 
covering  the  bones. — Complications.  Uterus  retroverted  and  bound  down. —  Treat- 
ment. An  attempt  to  open  the  vagina  was  followed  by  an  abscess  ;  afterwards 
enough  had  been  gained  to  close  the  fistula  with  11  sutures  ;  4  operations  after- 
wards to  close  an  opening  in  the  median  line  only  large  enough  to  admit  a  blunt 
hook  ;  all  cicatricial  tissue,  and  opened  after  removal  of  the  sutures. — Duration  of 
Treatment,  12  months;  Result,  improved. — Remarks.  Never  returned;  opening 
may  have  closed  by  contraction  of  cicatricial  tissue. 

80.  Admitted  Jan.  26,  1868.     Age  29.     Age  at  marriage  17.     No.  of  children  2 ;  of 
miscarriages  1. 

History.  In  labor  78  hours :  stillborn ;  the  body  remained  undelivered  36 
hours  after  passage  of  the  head  ;  physician  then  called  in,  who  removed  the  body 
by  traction  ;  escape  of  urine  from  the  birth  ;  5  months  in  bed  ;  one  child  since  at 
7  months,  which  was  removed  by  forceps. — Extent  of  Lesion.  Great  loss  of  tissue 
involving  cervix  and  base  of  the  bladder  ;  slough  of  the  perineum  ;  tissues  all  lost 
behind  the  left  ramus. — Complications.  Cicatricial  tissue  filling  the  cul-de-sac. — 
Treatment.  Required  very  extensive  dissection  and  removal  of  cicatricial  tissue  ; 
2  operations  necessary  :  one  to  close  the  fistula  to  the  ramus  ;  then  a  flap  was  taken 
from  the  lateral  wall  to  cover  the  opening  behind  the  bone. — Duration  of  Treat- 
ment, 6  weeks  ;  Result,  cured. — Remarks.     Had  5  operations  previous  to  admission. 

81  (lxxv.).  Admitted  Jan,  30,  1868.  Age  35.  Age  at  marriage  33.  No.  of 
children  1. 
History.  In  labor  123  hours  :  delivered  with  forceps  ;  stillborn  ;  two  days  after 
delivery  lost  control  of  the  urine  ;  for  a  month  it  was  thought  that  she  would  die. 
— Extent  of  Lesion.  Vagina  shortened  ;  cervix  and  posterior  cul-de-sac  lost ;  in 
the  mass  of  cicatricial  tissue  the  os  could  not  be  found,  or  any  remains  of  the  cer- 
vix except  a  hard  mass,  thought  to  be  the  posterior  lip  ;  it  was  only  when  on  the 
knees  and  elbows  that  the  fistula  could  be  brought  into  view  ;  by  contraction,  the 
fistula  was  drawn  to  one  side  and  somewhat  behind  the  uterus. — Complications. 
Uterus  retroverted  and  fixed  in  the  pelvis  from  a  general  cellulitis  after  labor. — 
T'reutment.  After  some  dissection  in  the  cul-de-sac,  the  transverse  fistula  was 
closed  by  8  sutures  in  the  axis  of  the  vagina  ;  two  weeks  after,  a  small  opening 
formed ;  while  freeing  the  parts  for  the  second  operation,  cut  into  the  peritoneal 
cavity ;  no  bad  result,  and  was  closed  with  the  fistula  by  the  same  operation. — 
Duration  of  Treatment,  18  weeks  ;  Result,  cured. — Remarks.  Peritoneal  cavity  opened 
by  accident  while  freeing  the  edges  of  the  fistula. 

82.  Admitted  Yeh.  10,  1868.     Age  28.     Age  at  marriage  24.     No.  of  children  3. 

Hisfori/.  In  labor  55  hours  ;  delivered  by  forceps  ;  the  bladder  was  emptied  fre- 
quently ;  the  urine  began  to  escape  a  week  after  delivery. — Extent  of  Lesion. 
There  was  a  laceration  of  the  cervix  through  the  vaginal  wall  to  the  neck  of  the 
bladder,  which  closed  from  above  downward  through  the  cervix ;  the  whole  neck 


692  CASES    OF    VESICO-VAGINAL    FISTULA 

of  the  uterus  sloughed. —  Complications.  The  uterus  was  retroverted  and  bound 
down  by  adhesions  from  an  old  cellulitis. — Treatment.  In  consequence  of  the 
adhesions,  the  sides  could  not  be  brought  together,  nor  could  they  be  freed  by 
dissection,  and  were  therefore  united  by  8  sutures  transverse  to  the  axis  of  the 
vagina. — Duration  of  Treatment,  8  weeks  ;  Result,  cured. 

83.  Admitted  Feb.  25,  1868.  Age  31.  Age  at  marriage  23.  No.  of  children  1. 
History.  In  labor  60  hours  :  ergot ;  delivered  by  forcej^s  ;  bladder  emjptied  fre- 
quently. Extent  of  Lesion.  Loss  of  the  base  and  neck  of  the  bladder,  with  a 
portion  of  the  urethra  ;  fistula  from  one  ramus  to  the  other  ;  prolapse  of  the 
fundus  of  the  bladder  through  the  opening. —  Complications.  Partial  atresia  of  the 
vagina. —  Treatment.  2  operations  ;  the  bands  were  divided  and  a  glass  plug 
used  for  several  months  ;  first  operation  on  the  knees  and  elbows ;  5  sutures  ; 
small  opening  closed  by  a  second  operation,  using  5  sutures. — Duration  of  Treat- 
ment, 6  months  ;  Result,  cured. 

84.  Admitted  Feb.  29,  1868.     Age  35.     No.  of  children  6  ;  of  miscarriages  1. 
History.     In   labor   53  hours  :    failed  to  apply  the  forceps ;    craniotomy ;  child 

weighed  9^  pounds  ;  the  bladder  was  not  emptied  ;  urine  began  to  escape  on  the 
following  day.  Injured  four  years  before  admission. — Extent  of  Lesion.  Fistula 
in  front  of  the  neck  of  the  uterus  extending  the  width  of  the  vagina  ;  the  open- 
ing had  been  circular,  but  now  drawn  into  a  crescentic  shape  by  bands  filling  the 
posterior  cal-de-sac  ;  the  fundus  of  the  bladder  protruded  through  the  fistula. — 
Complications.  The  anterior  lip  sloughed  away  ;  the  os  was  occluded  and  could 
not  be  found  ;  retained  menstrual  blood. — Treatment.  Evacuated  the  uterine 
cavity  ;  the  bands  were  dissected  up  so  as  to  free  the  angles  of  the  fistula  ;  this 
was  closed  with  great  difficulty  on  account  of  the  loss  of  the  cervix  ;  18  sutures  ; 
the  line  being  three  inches  long. — Duration  of  Treatment,  4  weeks  ;  Result,  cured. 

85.  Admitted  March  1,  1868.     Age  35.     Age  at  marriage  33.     No.  of  children  1. 
History.     In  labor  4  days  and  delivered  with  forceps  ;  no  further  particulars. — 

Extent  of  Lesion.  Large  fistula  in  front  of  the  neck  of  the  uterus  ;  portion  of  the 
cervix  destroyed. — Complications.  Cicatricial  tissue. —  Treatment.  2  operations. — 
Duration  of  Treatment,  3  months  ;   Result,  cured. 

86.  Admitted  March  11,  1868.     Age  33.     Age  at  marriage  24.     No.  of  children  2. 
History.     In  labor   20   hours  :    natural   delivery ;    bladder  not  emptied  for   36 

hours.  Extent  of  Lesion.  Fistula  half  an  inch  in  diameter  and  just  in  front  of 
the  cervix. —  Treatment.  One  operation  ;  failed  in  consequence  of  menstruation 
coming  on  immediately  after  the  operation. — Duration  of  Treatment,  4  weeks  ; 
Result,  not  improved. — Remarks.     Never  returned. 

87.  Admitted  March  24,  1868.     Age  27.     Age  at  marriage  23.     No.  of  children  8  ; 

of  miscarriages  2. 
History.  In  labor  34  hours  :  natural  delivery  ;  child  weighed  13  pounds  ;  face 
presentation  ;  stillborn  ;  urine  began  to  escape  on  the  13th  day. — Extent  of  Lesion. 
Fistula  oval  shaped  ;  entire  base  of  the  bladder  had  been  lost ;  sloughing  in  the 
posterior  cal-de-sac. — Complications.  Mouth  of  the  right  ureter  in  the  edge  of  the 
fistula. —  Treatment.  One  operation  to  divide  bands,  the  other  to  close  the  fistula  ; 
21  sutures  used. — Duration  of  Treatjnent,  7  weeks  ;  Result,  cured. — Remarks.  After 
her  discharge,  a  small  opening  made  by  traction  ;  this  was  closed  afterwards  by 
7  sutures. 

88  (lxxiii.).  Admitted  April  8,  1868.  Age  27.  Ago  at  marriage  23.  No.  of 
children  1. 
History.  In  labor  103  hours  :  failed  in  the  attempt  to  apply  the  forceps  ;  deliv- 
(ired  by  craniotomy  ;  the  bladder  \^a,s  not  emptied  until  just  before  delivery  ;  urine 
afterwards  retained  for  a  week,  when  it  suddenly  escaped  in  larger  quantity;  did 
not  recover  for  several  montbs. — Extent  of  Lesion.  A  fistula  situated  in  the  median 
line  and  centre  of  the  base  of  the  bladder  ;  the  opening  was  circular  and  half  an 
inch  only  in  diamc^tor ;  it  had  been  caused  by  a  laceration  of  the  anterior  lip  of 
the  uterus,  which  had  extended  along  the  base  of  the  bladder  for  some  distance 
beyond  the  lower  edge  of  tlie  prescmt  opening. — Complications.  On  admission  still 
complained  of  numbness  in  the  riglit  foot. —  Treatment.     After  removing  the  cica- 


RESULTING    FROM    CIIILDEIRTII.  G93 

tricial  edges  of  the  fistula  into  liealtliy  tissue,  it  was  closed  without  difficulty  by 
G  sutures,  making  a  line  of  union  an  incli  and  a  quarter  in  length  ;  witliout  any 
apparent  cause,  an  attack  of  peritonitis  developed  on  the  4th  day  ;  this  subsided, 
anil  union  found  perfect  when  the  sutures  were  removed  ;  on  the  35tli  day  symp- 
toms of  pyaemia,  and  she  died  six  weeks  after  the  operation. — Duration  of  Treat- 
ment, G  weeks ;  Result,  died. — Remarks.  Had  been  operated  on  previous  to 
admission. 

89.  Admitted  April  15,  1868.     Age  33.     Age  at  marriage  29.     No.  of  children  2. 
History.     In    labor    42    hours :    forceps  ;    loss  of  urine  20  days    after  delivery. 

Injured  five  months. — Extent  of  Lesion.  Loss  of  the  upper  half  of  the  bladder; 
the  vagina  shortened  by  contraction,  and  the  fistula  hidden  by  the  tissues  in  front 
of  the  neck  of  the  bladder  ;  a  fold  was  drawn  back  by  cicatricial  tissue  in  the  cul- 
de-sac. —  Treatment.  Until  the  bands  were  divided  the  fistula  seemed  a  small  one  ; 
it  was  then  transverse  and  admitted  two  fingers  ;  first  operation  very  difficult ;  11 
sutures  ;  two  small  openings  left ;  closed  as  one  by  7  sutures. — Duration  of  Treat- 
ment, 10  weeks  ;  Result,  cured. 

90.  Admitted  May  4,  1858.     Age  24.     Age  at  marriage  24.     No.  of  children  4. 
Historij.     In   labor   34  hours  :  chloroform,  forceps  ;    bladder  not   emptied  ;  lost 

the  urine  on  the  5th  day. — Extent  of  Lesion.  Fistula  in  front  and  a  little  to  the 
left  of  the  neck  of  the  uterus,  half  an  inch  in  diameter  ;  there  had  been  an  adhe- 
sion in  the  walls  of  the  vagina,  shutting  up  the  neck  of  the  uterus  ;  mouth  of  the 
pelvic  abscess  near  the  edge  of  this  septum ;  the  fistula  was  drawn  behind  the 
right  ramus. — Complications.  As  the  result  of  an  examination  before  admission, 
she  had  cellulitis  and  a  pelvic  abscess. —  Treatment.  Oj^eration  difficult,  as  the 
parts  were  unyielding  from  the  old  cellulitis  ;  difficulty  with  the  catheter  ;  opera- 
tion only  partially  successful ;  second  operation,  with  11  sutures,  successful. — 
Duration  of  Treatment,  13  weeks ;  Result,  cured. 

91.  Admitted  June  1,  18G8. 

History.  No  record. — Fistula  admitting  two  fingers,  situated  in  front  of  the  ante- 
rior lip,  which  sloughed  ;  had  been  a  laceration  through  the  anterior  lip  and  in 
the  vaginal  axis,  but  made  transverse  by  cicatricial  tissue  on  each  side  of  the  cer- 
vix.—  Treatment.  2  operations  :  one  for  opening  the  cul-de-sac,  and  the  other  for 
closing  the  fistula. — Duration  of  Treatment,  11  weeks  ;  Result,  cured. 

92.  Admitted  Oct.  5,  1868.     Age  34.     Age  at  marriage  23.     No.  of  children  8. 
History.     In  labor  60  hours  :  ergot,  forceps  ;  child  large  and  stillborn  ;  bladder 

emptied. — Extent  of  Lesion.  Laceration  of  the  cervix  through  the  anterior  lip  and 
base  of  the  bladder  ;  closed  from  above,  leaving  a  sinus  into  the  uterine  canal 
above  the  vaginal  junction. —  Treatment.  AVith  scissors  produced  the  original  con- 
dition ;  removed  the  tract  of  the  sinus  and  closed  the  lips  with  4  sutures,  which, 
were  removed  on  the  Stli  day. — Duration  of  Treatment,  6  weeks  ;  Result,  cured. 

93.  Admitted  Oct.  9,  1868.     Age  28.     Age  at  marriage  20.     No.  of  children  1. 
History.     In  labor  48  hours  :  breech  presentation ;  weighed  12  pounds  ;  urine 

escaped  from  the  time  of  delivery. — Extent  of  Lesion.  Nothing  left  of  the  base  of 
the  bladder  ;  tissue  gone  from  behind  the  rami ;  inversion  of  the  bladder  through 
the  fundus. — Complications.  Loss  of  the  entire  urethra. — Treatment,  10  operations 
during  four  years,  during  which  time  the  fistula  was  bridged  over  to  a  small  open- 
ing, and  a  new  urethra  was  made. — Result,  improved. 

94.  Admitted  Oct.  17,  1868.     Age  24.     Age  at  marriage  18.     No.  of  children  4. 
History.     In  labor   30  hours  :    delivered   by  efforts  of  nature,  stillborn  ;  irrine 

began  to  escape  on  the  4th  day.  Injured  four  months. — Extent  of  Lesion.  The 
fistula  extended  from  one  ramus  to  the  other  and  involved  a  loss  of  at  least  two- 
thirds  of  the  base  of  the  bladder  ;  it  was  drawn  into  shape  so  that  its  corners 
were  square. —  Treatment.  Closed  by  4  operations,  the  first  one  requiring  15  sutures. 
— Duration  of  Treatment,  5  months  ;   Result,  cured. 

95.  Admitted  Oct.  19,  1868,     Age  33.     Age  at  marriage  20.     No.  of  children  3. 
History.     In  labor  30  hours  :   after  the  pains  had  ceased,  the  body  was  "  deliv- 
ered by  hand,"  stillborn;  the  bladder  was  emptied  ;  urine  escaped  shortly  after 


694  CASES    OF    VESICO-VAGINAL    FISTULA 

delivery. — Extent  of  Lesion.  At  the  depth  of  an  inch  and  a  half  from  tke  outlet 
the  vagina  terminated  along  the  posterior  edge  of  the  fistula ;  the  finger  passed 
directly  into  the  bladder  ;  the  fistula  was  transverse  from  one  side  of  the  vagina  to 
the  other. — Complications.  Atresia  of  the  vagina. —  Treatment.  The  vagina  opened 
up  to  the  depth  of  four  inches,  and  a  glass  plug  worn  for  three  months  ;  in  con- 
sequence of  the  cicatricial  tissue,  5  operations  were  necessary  before  the  fistula 
closed. — Duration  of  Treatment,  4  months  ;  Result,  cured. 

9fi.  Admitted  Oct.  23,  1868.     Ag&  35.     Age  at  marriage  23.     No.  of  children  1. 

History.  In  labor  72  hours  :  forceps  used  ;  urine  began  to  escape  a  week  after 
delivery.  Injured  eleven  years  before  admission. — Extent  of  Lesion.  The  whole 
base  of  the  bladder  and  all  but  a  quarter  of  an  inch  of  the  urethra  was  lost ;  the 
vagina  was  constricted  at  two  points  ;  at  the  first  the  finger  could  be  jiassed,  but 
only  directly  into  the  bladder. — Complications.  Atresia  of  the  vagina. —  Treatment. 
The  vagina  was  oi^ened,  and  a  glass  plug  worn  for  two  months  ;  fistula  closed  by 
17  sutures,  and  was  3i  inches  long  ;  only  a  small  opening  left  just  behind  the  left 
ramus  ;  2  operations  afterwards  for  closing  small  opening. — Duration  of  Treatment, 
6  months  ;  Result,  cured. — RemarJcs.  As  the  line  contracted,  the  urine  would 
sometimes  escape  from  the  short  urethra  when  walking. 

97.  Admitted  Oct.  27,  1868.     Age  20.     Age  at  marriage  18,     No.  of  children  1. 
Histori/.     In  labor  96  hours  :  delivered  by  forceps  ;  no  information  in  regard  to 

emptying  the  bladder,  but  the  urine  escaped  from  the  time  of  delivery. — Extent  of 
Lesion.  Loss  of  the  base  of  the  bladder,  cul-de-sac,  and  neck  of  the  uterus  ; 
vagina  shortened  and  contracted  with  a  transverse  fistula  at  the  neck  of  the 
bladder. —  Complications.  Curvature  of  the  spine  and  deformed  pelvis,  with  atresia 
of  the  bladder. —  Treatment.  In  consequence  of  the  narrowed  pelvis,  the  atresia 
was  allowed  to  remain  so  as  to  prevent  a  future  pregnancy ;  the  fistula  was  closed 
with  7  sutures. — Duration  of  Treatment,  8  weeks  ;  Result,  cured. 

98.  Admitted  Dec.  1,  1868.     Age  30.     Age  at  marriage  18.     No.  of  children  3. 
History.     In  labor  72  hours  :  delivered  by  forceps  ;  stillborn,  large  child  ;  urine 

escaped  on  delivery.  Injured  three  years  before  admission. — Extent  of  Lesion.  A 
fistula,  one  inch  and  a  quarter  in  length,  situated  just  in  front  of  the  cervix  and 
a  little  to  the  left ;  the  opening  is  transverse  to  the  axis  of  the  vagina  and  in  the 
midst  of  cicatricial  tissue. —  Treatment.  Fistula  closed  by  13  sutures  ;  successful, 
but  20  days  after  began  to  lose  the  urine ;  small  opening  closed  by  8  sutures ; 
again,  another  operation  with  7  sutures  ;  successful. — Duration  of  Treatment,  5 
mouths  ;  Result,  cured. 

99.  Admitted  Dec.  23,  1868.     Age  49.     Age  at  marriage  21.     No.  of  children  10  ; 
of  miscarriages  1. 

History.  In  labor  60  hours  :  had  puerperal  convulsions  ;  delivered  with  forceps  ; 
loss  of  itrine  from  time  of  delivery.  Injured  four  years  before  admission  ;  still- 
born.— Extent  of  Lesion.  Laceration  of  the  cervix  on  the  left  side,  wliich  passed 
into  the  vaginal  wall ;  the  opening  is  at  the  bottom  of  a  deep  sulcus  passing 
obliquely  from  right  to  left,  and  extended  from  the  internal  os  into  the  bladder  ; 
it  was  difficult  to  bring  the  parts  into  view. — Complications.  Puerperal  mania. — 
Treatment.  2  operations  ;  after  each  the  puerperal  mania  was  developed,  and  it 
was  impossible  to  keep  her  quiet  ;  her  general  health  was  worse  at  the  time  of  her 
discharge,  but  the  opening  was  smaller. — Duration  of  Treatment,  4  months  ;  Result, 
improved. 

100.  Admitted  April  24,  1869.     Age  35.     Age  at  marriage  25.     No.  of  children  4. 
History.     In  labor  72  hours  :  delivered  by  tlie  eflbrts  of  nature  ;  child  in  a  state 

of  decomposition  ;  escape  of  urine  one  week  after  delivery. — Extent  of  Lesion.  A 
fistula  exit^ted  behind  a  contraction  of  the  vagina ;  when  this  liad  been  opened, 
the  fistula  was  found  lialf  an  inch  in  front  of  the  cervix,  transverse  to  the  axis  of 
the  vagina,  and  large  enough  to  admit  two  fingers. — Cnmplirations.  Partial  atresia 
of  the  vagina. —  Treatment.  Certain  banrls  were  divided  to  free  the  edges  ;  these 
were  secured  by  14  sutures  ;  tlie  parts  had  united  wlien  the  sutures  were  removed, 
l)at  on  the  day  after  jumped  out  of  bed,  and  twice  afterwards  the  ]>arts  separated, 
but  finally  closed. — Duration  of  Treatment,  12  months  ;  Result,  cured. 


RESULTING    FROM    ClIILDBIRTH.  695 

101.  Admitted  May  6,  1S69.   Age  36.   Age  at  marriage  25.     No.  of  children  5  ;  of 
miscarriages  1. 

History.  Second  labor  lasted  48  hours  :  terminated  by  forceps  ;  urine  escaped 
4  days  after  delivery  ;  three  children  born  shice. — Extent  of  Lesion.  Originally 
the  laceration  extcncled  through  the  anterior  lip  to  within  an  inch  of  the  neck  of 
tlie  bladder,  and  then  turned  towards  and  as  far  as  the  left  ramus. —  Treatment. 
This  case  had  been  operated  on  before  admission,  and  about  half  from  each  end 
had  been  closed  ;  the  remaining  opening  was  closed  by  6  sutures. — Duration  of  Treat- 
ment, 4  weeks  ;  litsult,  cured. — Remarks.  Had  been  operated  on  with  benefit  pre- 
vious to  admission. 

102.  Admitted  May  7,  1869.     Age  38.     Age  at  marriage  20.     No.  of  children  5. 
History.     In  labor  17  hours  :  attempted  to  deliver  with   forceps,  then  version, 

and  delivery  finished  by  craniotomy,  under  ether  ;  the  head  was  very  large  ; 
it  was  said  that  the  head  was  impacted  only  one  hour  ;  the  urine  escaped  one 
month  after.  Injured  one  year  before  admission. — Extent  of  Lesion.  A  laceration 
originally  extended  tlii'ough  the  anterior  lip  of  the  cervix  and  along  the  median 
line  into  the  base  of  the  bladder ;  the  tear  through  the  cervix  closed,  leaving  the 
opening  in  the  base  of  the  bladder. —  Treatment.  A  V-shaped  piece  was  removed 
from  the  cervix  before  the  fistula  could  be  closed  ;  this  was  done  by  7  sutures. — 
Duration  of  Treatment,  9  weeks  ;  Result,  cured. 

103.  Admitted  Oct.  13,  1869.     Age  24.     Age  at  marriage  22.     No.  of  children  1. 
Historj.     In  labor  61  hours  :  delivered  with  forceps  ;  child  stillborn  ;  three  days 

after  delivery  the  urine  began  to  escape  ;  confined  to  bed  for  three  months. — Extent 
of  Lesion.  An  opening  high  up  behind  the  symphysis,  and  difficult  to  bring  into 
view ;  the  opening  is  but  three-quarters  of  an  inch  in  length,  and  in  the  midst  of 
cicatricial  tissue. —  Complications.  In  the  habit  of  taking  large  quantities  of  mor- 
phine ;  extensive  laceration  of  the  perineum. —  Treatment.  After  the  cicatricial 
tissue  had  been  removed,  the  opening  was  two  inches  and  a  half  in  length. — 
Duration  of  Treatment,  12  weeks  ;  Result,  cured. 

104.  Admitted  Oct.  14,  1869.     Age  30.     Age  at  marriage  19.     No.  of  children  6  ; 
of  miscarriages  2. 

History.  In  labor  22  hours  :  delivered  by  forceps  ;  urine  escaped  from  time 
of  delivery. — Extent  of  Lesion.  Loss  of  the  base  and  neck  of  the  Idadder,  but 
the  sides  had  become  united  so  as  to  leave  two  openings  :  one  just  anterior  to  the 
cervix  and  the  other  directly  behind  the  pubes,  at  which  point  the  urethra  is 
closed. —  Complications.  Fistula  of  the  left  ureter  ;  recto-vaginal  fistula  ;  occlusion 
of  the  urethra. —  Treatment.  The  ojjenings  into  the  bladder  were  closed  by  two 
separate  operations  without  difficulty  ;  some  urine  was  lost  when  the  small  fistula 
in  the  ureter  was  found  ;  several  operations  were  performed  to  close  this,  but 
without  success. — Duration  of  Treatment,  4  months  ;  Result,  cured. — Remarks.  Both 
vesical  and  rectal  fistulce  were  closed  ;  died  afterwards  of  renal  disease. 

105.  Admitted  Oct.  19,  1868.     Age  30.     Age  at  marriage  20.     No.  of  children  1. 
History.     In  labor  48  hours  :  no  interference  ;   no  control  of  urine  after  delivery. 

— Extent  of  Lesion.     Base  of  the  bladder   and  the  urethra  destroyed. —  Treatment. 

14  operations,  six  of  which  were  for  reconstruction  of  the  urethra. — Duration  of 
Treatment,  18  months  ;  Result,  not  given. 

106.  Admitted  Oct.  26,  1869.     Age  28.     No.  of  children  7  ;  of  miscarriages  1. 
History.     In  labor  48  hours :  craniotomy ;  six  days  after  delivery  urine  began 

to  escape. — Extent  of  Lesion.  Base  of  the  bladder  and  anterior  lip  of  the  uterus 
lost ;  the  fistula  is  over  two  inches  in  length  and  extends  from  ramus  to  ramus  ; 
these  bones  were  denuded  of  all  tissue  but  the  periosteum. —  Complications.  Pro- 
lapse of  the  posterior  wall  and  fundus  of  the  bladder. —  Treatment.  Required 
extensive  dissection  to  bring  the  parts  together  without  making  traction  on  the 
short  urethra  ;  the  line  of  union  was  three  inches  long  and  brought  together  by 

15  sutures. — Duration  of  Treatment,  4:  months  ;  Result,  cured. — Remarks.  Required 
three  months  of  preparatory  treatment. 


696  CASES    OF    YESICO-YAGINAL    FISTULA 

107.  Admitted  Dec.  27,  1869.     Age  24.     Age  at  marriage  22.     No.  of  children  2. 
History.     In  labor  36  hours  :  delivered  \yith  forceps  ;  stillborn ;    nrine  escaped 

from  the  time  of  delivery. — -Extent  of  Lesion.  Laceration  through  the  anterior  lip 
of  the  uterus,  in  the  median  line,  leaving  a  small  opening  at  the  vaginal  junction. 
—  Treatment.  Necessary  to  remove  a  Y-shaped  piece  from  the  cervix  to  prevent 
the  formation  of  a  fold  ;  the  surfaces  were  then  united  by  8  sutures. — Duration  of 
Treatment,  7  weeks  ;   Result,  cured. 

108.  Admitted  Jan.  8,  1870.     Age  37.     Age  at  marriage  26.     No.  of  children  4  ;  of 
miscarriages  5. 

History.  In  labor  40  hours  :  delivered  by  forceps  ;  urine  began  to  escape  on 
the  day  after  delivery.  Injured  two  years. — Extent  of  Lesion.  Fistula  in  the 
median  line,  ruidway  between  the  neck  of  the  bladder  and  cervix  uteri ;  the  open- 
ing was  large  enough  to  admit  the  finger,  but  there  had  been  a  greater  loss  of  tissue 
and  contraction. — Complications.  Cystitis,  which  required  several  months'  treat- 
ment before  fit  for  an  operation. — Treatment.  The  fistula  was  closed  by  7  sutures, 
after  the  cystitis  had  been  relieved,  which  required  4  months. — Duration  of  Treat- 
ment, 5  months ;  Result,  cured. — Remarks.  Had  been  operated  on  previous  to 
admission. 

109.  Admitted  Feb.  6,  1870.     Age  31,     Age  at  marriage  29.     No.  of  children  1. 
History.     In  labor  54  houi's  :    pains   ceased  and  head  on  the  perineum  for  24 

hours  ;  ergot  given  without  marked  eflFect ;  delivered  by  traction  ;  stillborn  ;  loss 
of  urine  from  the  2-1  week. — Extent  of  Lesion.  Loss  of  the  middle  third  of  the 
base  of  tlie  bladder,  extending  from  one  side  of  the  vagina  to  the  other. —  Compli- 
cations. Extensive  laceration  of  the  perineum. —  Treatment.  Three  months'  pre- 
paratory treatment  needed  ;  operation  successful,  but  a  week  after  removing  the 
sutures  began  to  lose  the  urine  ;  small  opening  behind  the  ramus,  closed  by  a 
second  operation. — Duration  of  Treatment,  3  months  ;  Result,  cured. — Remarks.  Had 
a  child  18  months  after  without  trouble. 

110.  Admitted  March  3,  1870.     Age  43.     Age  at  marriage  20.     No.  of  children  11. 
History.     In  labor  56  hours  :  head  impacted  for  24  hours  ;  stillborn  ;  delivered 

by  forceps  ;  urine  lost  from  time  of  delivery.  Injured  six  years. — Extent  of  Lesion. 
A  small  fistula  in  front  of  the  cervix,  hidden  by  folds  and  closed  with  great  diffi- 
culty ;  afterwards  found  the  urine  escaping  from  the  os  uteri ;  there  had  been 
a  deep  laceration  through  the  body  and  cervix  in  tlie  median  line,  which  partly 
closed. —  Treatment.  She  required  five  months  of  preparatory  treatment;  after  the 
fistula  had  been  closed,  urine  escaped  from  the  os  ;  as  the  opening  into  the  bladder 
could  not  be  detected,  and  on  account  of  her  age,  it  was  thought  best  to  close  the 
OS  uteri ;  10  sutures  used. — Duration  of  Treatment,  11  weeks  ;  liesult,  cured. 

111.  Admitted  April  19,  1870.     Age  31.     Age  at  marriage  17.     No.  of  children  1. 
History.     In  labor  10  hours,  wlien  delivery  was  accomplished  with  forceps  :  the 

urine  escaped  about  8  days  after  delivery;  injured  seven  months. — Extent  of 
Lesion.  A  fistula,  an  inch  in  diameter,  situated  at  the  neck  of  the  bladder,  was 
almost  concealed  by  cicatricial  bands,  which  narrowed  the  vagina ;  beyond  the 
fistula  the  vagina  was  destroyed. — Complications.  Atresia  of  the  vagina,  and 
urethra  occluded. —  Treatment.  It  required  four  months  to  open  the  vagina,  during 
which  time  the  glass  plug  was  used  ;  fistula  closed  by  8  sutures  ;  operation  suc- 
cessful;  after  a  short  time,  began  to  lose  urine,  due  to  a  baud  pulling  the  urethra 
backward  ;  by  removing  this  band  the  retentive  power  was  gained. — Duration  of 
Treatment,  5  months  ;  Result,  cured. 

112.  Admitted  April  20,  1870..     Age  19.     Age  at  marriage  17.     No.  of  children  1. 
History.     In  labor  93  hours  :    delivered  by  forceps  ;  escape  of  urine  from  time 

of  delivery.  Injured  a  year  previous  to  admission. — Extent  of  Lesion.  A  fistula 
involving  nearly  the  whole  base  of  the  bladder,  and  extended  from  one  ramus  to 
the  other. —  Treatment.  3  op(>rations  :  first,  11  .sutures  used  ;  closed  all  but  at  the 
neck  of  the  bladder,  wlicre  the  catheter  came  in  contact ;  next  operation  again 
failed  ;  then  cut  a  band  whicli  dr(!w  tlie  neck  of  the  bladder  backward  ;  after 
this  the  opening  remained  closed. — Duration  of  Treatment,  8  months ;  Result, 
cured. 


RESULTING    FROM    CUILDLIRTU.  G97 

113.  Admitted  Juno  14,  1870.     Age  33.     Age  at  marriage  15.     No.  of  children  3. 
JJistori/.     Last  labor,  teriiiinated  by  forceps  ;  loss  of   urine  since  delivery  ;  no 

further  particulars  given. — Extent  of  Lesion.  A  small  opening  at  the  neck  of  the 
bladder. —  Treatment.  1  operation  ;  5  sutures. — Duration  of  Treatment,  b  months  ; 
Result,  cured. 

114.  Admitted  Sept.  22,  1870.     Age  43.     No.  of  children  1. 

Uistori).  Labor  dilticult :  time  not  given ;  delivered  with  forceps  ;  escape  of 
urine  from  delivery. — Extent  of  Lesion.  A  crescentic  shaped  fistula  from  the  loss 
of  the  lower  half  of  the  base  of  the  bladder ;  the  corners  were  drawn  up  by 
bands  on  each  side  of  the  cervix. —  Treatment.  First  operation,  13  sutures  ;  small 
opening  ;  this  was  closed  by  a  second  operation  ;  again  opened  and  finally  closed 
by  a  tliird  operation. — Duration  of  Treatment,  3  weeks  ;  liesult,  cured. 

115.  Admitted  Oct.  4,  1870.     Age  35.     Age  at  marriage  27.     No.  of  children  1. 
Histori/.    In  labor  3G  hours  :  forceps  failed;  craniotomy  afterwards  ;  escape  of  urine 

from  delivery.  Injured  fourteen  years. — Extent  of  Lesion.  Loss  of  the  ujiper  third 
of  the  anterior  wall  of  the  vagina,  the  upper  edge  of  which  was  formed  by  the 
cervix. —  Treatment.  A  V-shaped  piece  was  removed  from  the  cervix,  and  the 
edges  of  the  fistula  brought  together  with  6  sutures  ;  when  these  were  removed, 
there  was  no  union  ;  a  second  operation,  after  some  preparatory  treatment,  was 
successful. — Duration  of  Treatment,  22  weeks  ;  liesult,  cured. — Remarks.  Twice 
operated  on  previous  to  admission. 

IIG.  Admitted  Oct.  4,  1870.     Age  26.     Age  at  marriage  24.     No.  of  children  1. 

Histori/.  In  labor  4  days  :  delivered  with  forceps  ;  stillborn  ;  has  had  a  loss  of 
\irine  since  her  delivery.  Injured  five  months. — Extent  of  Lesion.  Loss  of  the 
middle  third  of  the  anterior  wall ;  the  fistula  extended  from  one  side  of  tlie 
vagina  to  the  other,  and  of  a  crescentic  shape  from  bands  on  each  side  of  the  cer- 
vix extending  into  the  cul-de-sac. —  Treatment.  Three  months  preparatory  treat- 
ment ;  the  cicatricial  bands  were  divided,  the  edges  of  the  fistula  denuded  and 
brought  together  by  13  sutures  ;  small  opening  in  the  midst  of  cicatricial  tissue  ; 
second  operation,  no  union  ;  6  operations  more  before  it  was  closed. — Duration  of 
Treatment,  19  months  ;  Result,  cured. — Remarks.  Had  phlebitis  along  the  course 
of  the  femoral  vessels  on  the  right  side,  after  the  second  operation. 

117.  Admitted  Oct.  5,  1870.     Age  45.     Age  at  marriage  30.     No.  of  children  5  ;  of 
miscarriages  3. 

Histori/.  No  particulars  given  beyond  th.e  statement  that  the  last  labor  was  a 
very  difiicult  one  and  occurred  four  years  previous  to  admission. — Extent  of 
Lesion.  A  fistula  formed  by  the  sloughing  of  the  upper  tliird  of  the  anterior  wall 
of  the  vagina,  together  with  the  neck  of  the  uterus  along  tlie  lower  edge  ;  more  of 
the  vaginal  surface  had  sloughed  than  from  the  base  of  the  bladder,  so  that  the 
edge  was  slanting  ;  on  the  upper  side  the  tissue  were  gone  as  far  as  tlie  cervix, 
and  the  remains  of  the  cervix  projected  into  the  bladder. —  Com/ylications.  L'terus 
retroverted.' — Treatment.  Cicatricial  tissue  covered  a  portion  of  the  opening  like  a 
hood  ;  from  the  i^osition  of  tlie  uterus,  it  was  necessary  to  close  the  edges  of  the 
fistula  over  the  cervix,  leaving  it  in  the  bladder  ;  this  was  done  by  9  sutures. — 
Duration  of  Treatment,  9  weeks  ;  Result,  cured. — Remarks.  Menstruated  for  the  first 
time  at  25  years  of  age. 

118.  Admitted  Dec.  7,  1870.     Age  43.     Age  at  marriage  19.     No.  of  children  11. 
History.     In  last  labor  36  hours  :  delivered  by  forceps  ;  escape  of  the  urine  after 

delivery. — Extent  of  Lesion.  Loss  of  the  base  of  the  bladder  and  cul-de-sac. — 
Treatment.     3  operations. — Duration  of  Treatment,  22  weeks  ;  Result,  cured. 

119.  Admitted  Sept.  25,  1871.     Age  33.     Age  at  marriage  29.     No.  of  children  3. 
Historij.     In  labor  48  hours  :  breech  presentation  ;  delivered  "  by  instruments," 

after  version  had  been  performed  ;  the  bladder  was  emptied  during  progress  of 
labor,  but  not  for  several  days  after,  when  it  began  to  escape  by  the  vagina. — 
Extent  of  Lesion.  The  whole  base  of  the  bladder,  including  the  neck  and  more 
than  half  the  urethra,  with  loss  of  cul-de-sac  ;  the  inner  face  of  the  ramus  on  the 
left  side  was  bared  of  all  tissue  ;  cicatricial  bands  on  each  side  of  the  cervix,  run- 
ning into  the  cul-de-sac. — Complications.     Had  a  rectal  fistula  which  gradually 


698  CASES    OF    VESICO-VAGINAL    FISTULA 

closed;  uretlira  occluded. —  Treatinent.  First  oijeration  after  dividing  the  bands 
and  opening  the  urethra  ;  10  sutures  ;  two  openings  left ;  closed  each  by  different 
operations,  one  of  which  had  to  be  repeated. — Duration  of  Treatinent,  9  months ; 
Result,   cured. — Remarks.     Afterwards  had  a  stone  removed  from  the  bladder. 

120.  Admitted  Oct.  3,  1871.     Age  33.     Age  at  marriage  23.     No.  of  children  1. 
History.     In  labor  60  hours  :    stillborn  ;  delivered  by  forceps  ;    urine  began  to 

escape  several  days  after  delivery. — Extent  of  Lesion.  Loss  of  the  lower  portion 
of  the  base  of  the  bladder  ;  after  contraction,  a  transverse  opening  was  left  extend- 
ing from  ramus  to  ramus. —  Treatment.  Tliere  was  so  little  tissue  covering  the  left 
ramus  that  it  was  very  difficult  to  denude  the  edges  and  to  introduce  the  sutures  ; 
13  sutures  used  ;  operation  successful  ;  afterwards  a  pin-hole  opening  was  found 
against  the  left  ramus  ;  this  closed  by  contraction. — Duration  of  Treatment,  9 
months ;  Result,  cured. 

121.  Admitted  Oct.  6,  1871.     Age  26.     No.  of  children  1. 

History.  In  labor  17  hours  :  delivered  by  forceps  ;  bladder  was  not  emptied  ; 
loss  of  urine  since  delivery  ;  confined  to  bed  9  weeks. — Extent  of  Lesion.  The 
entire  base  of  the  bladder  lost,  leaving  the  opening  crescentic  in  sliape,  with  the 
cornua  backward  ;  unable  to  find  any  vestige  of  the  uterus  left. —  Treatment.  The 
posterior  wall  of  the  vagina  was  united  to  the  neck  of  the  bladder ;  using  11 
sutures  ;  removed  12th  day. — Duration  of  Treatment,  3  months  ;  Result,  cured. 

122.  Admitted  Oct.  18,  1871.     Age  34.     Age  at  marriage  21.     No.  of  children  8. 
History.     In  the  7th  labor  was  injured  :  lasted  17  hours,  and  terminated  with 

forceps  ;  bladder  had  to  be  emptied  for  two  weeks,  at  the  end  of  which  time  the 
urine  was  lost.  Injured  fifteen  months. — Extent  of  Lesion.  A  small  opening  left 
in  front  of  the  cervix,  the  result  of  an  anterior  laceration. — Complications.  Exten- 
sive laceration  of  the  perineum. —  Treatment.  Fistula  closed  with  8  sutures. — 
Duration  of  Treatment,  4  weeks  ;  Result,  cured. 

123.  Admitted  Oct,  21,  1871.     Age  22.     No.  of  children  1. 

History.  Labor  25  hours  :  delivered  by  craniotomy ;  loss  of  urine  from  time 
of  delivery. — Extent  of  Lesion.  Fistula  in  the  median  line  near  the  cervix,  large 
enough  to  admit  the  index  finger. — Treatment.  2  operations  :  one  to  divide  bands, 
and  the  otlier  to  close  the  fistula. — Duration  of  Treatment,  8  weeks  ;  Result,  cured. 

124.  Admitted  Feb.  1,  1872.     Age  28.     Age  at  marriage  26.     No.  of  children  1. 
History.     In  labor  48  hours  :   delivered  by  forceps  ;  bladder  emptied  only  once 

during  labor. — Extent  of  Lesion.  Fistula  an  inch  in  diameter  just  in  front  of  the 
cervix. — Complications.  The  whole  vaginal  surface  covered  by  a  phosphatic  deposit. 
— Treatment.  1  operation,  but  it  reqiiired  months  of  preparatory  treatment. — 
Duration  of  Treatment,  8  months  ;  Result,  cured. 

125.  Admitted  Sept.  15,  1872.     Age  28.     Age  at  marriage  22.     No.  of  children  1. 
History.     Not  recorded. — Extent  of  Lesion.     Fistula  near  the  uterus,  near  the 

cervix,  and  half  an  inch  in  diameter. —  Treatment.  1  operation  ;  6  sutures  ; 
removed  the  10th  day. — Duration  of  Treatment,  4  weeks  ;  Result,  cured. 

126.  Admitted  Sept.  16,  1872. 

History.  Not  recorded. — Extent  of  Lesion.  Fistula  to  the  left  of  the  median 
line,  extending  to  tlie  side  of  the  cervix,  the  result  of  a  laceration. — Treatment. 
2  operations. — Duration  of  Treatment,  7  months  ;  Result,  cured. 

127.  Admitted  Sept.  21,  1872.     Age  40.     No.  of  children  1 ;  of  miscarriages  3. 
History.     Four,  days  in  labor  :    forceps  ;    loss  of  urine  from    time  of  delivery. 

Injured  three  years  ;  tliree  miscarriages  since. — Extent  of  Lesion.  Cervix  lacerated 
tlirongh  the  anterior  lip  into  tlie  bladder  ;  the  laceration  remained  unhealed. — 
Treatment.  1  operation  ;  8  sutures  :  4  tlirough  tlie  cervix  and  4  through  tlie  fis- 
tula.— Duration  of  Treatment,  3  weeks  ;  Result,  cured. 

128.  Admitted  ^e>j>i.  23,  1S72. 

History.  Could  get  no  information  beyond  the  existence  of  the  fistula  for  seven 
years. — Extent  of  Lesion.     One  fistula  is  immediately  to  the  right  of  the  median 


RESULTING  FROM  CHILDBIRTH.  699 

line  and  half  an  inch  from  tlio  cervix  ;  another  was  found  on  the  same  side,  near 
the  ramus,  as  if  the  llstuhi  liad  liealed  in  tlie  middle,  leaving  an  opening  at  each 
end. —  Treatment.  One  opening  was  closed  with  (J  sutures,  and  tlie  other  with  4. 
— Duration  of  Treatment,  3  mouths  ;  Result,  cured. 

129.  J[(/mi«ec?  Sept.  23,  1872.     Age  31.     No.  of  children  1  ;  of  miscarriages  1. 
Histortj.     In  labor  3'days  :  was  delivered  witli  forceps  ;  stillborn  ;  11  days  after 

delivery  involuntary  escape  of  urine  ;  miscarriage  since  birth  of  child. — Extent  of 
Lesion.  Laceration  of  the  cervix,  leaving  an  opening  into  tlie  bladder  close  to  the 
neck  of  the  uterus. —  Treatment.     1  operation  ;   (J  sutures. — Duration  of  Treatment, 

4  weeks  ;  Result,  cured. 

130.  Admitted  Sept.  23,  1872.     Age  26.     No.  of  children  1. 

History.  In  labor  24  hours  :  terminated  by  eflorts  of  nature  ;  stillborn  ;  urine 
escaped  at  the  end  of  a  week. — Extent  of  Lesion.  An  opening  existed  at  the  neck 
of  bladder  which  extended  from  bone  to  bone. — Complications.  A  recto-vaginal 
fistula. —  Treatment.  Before  closing  the  fistula,  the  cicatricial  bands  in  each  angle 
were  divided  so  as  to  free  the  corners  from  behind  the  rami ;  6  sutures  were  used. 
— Duration  of  Treatment,  2  months  ;  Result,  cured. — Remarks.  Rectal  fistula  closed 
afterward. 

131.  Admitted  Sept.  24,  1872.     No.  of  children  2. 

History.  Not  recorded. — Extent  of  Lesion.  A  small  opening,  large  enough  to 
admit  the  uterine  probe,  found  behind  each  ramus,  without  loss  of  tissue  between. 
— Complications.  An  encysted  stone  in  the  bladder,  which  was  not  discovered 
until  after  closing  the  fistula. —  Treatment.  Each  opening  was  closed  by  a  separate 
operation  ;  symptoms  of  cystitis  gradually  coming  on  after  the  operation,  led  to 
the  discovery  of  the  stone. — Duration  of  Treatment,  4  weeks  ;  Result,  cured. — 
Remarks.     The  stone  was  afterwards  removed  from  the  bladder. 

132.  Admitted  Sept.  24,  1872.     Age  30.     Age  at  marriage  20.     No.  of  children  1. 
History.     In  labor  24  hours  :  no  interference  ;  no  other  particulars  recorded. — 

Extent  of  Lesion.  Loss  of  the  whole  anterior  wall  of  the  vagina. —  Treatment. 
1  operation. — Duration  of  Treatment,  4  months  ;  Result,  improved. — Remarks,  Never 
returned  ;  result  unknown. 

133.  Admitted  mv.  21,  1872.     Age  21.     No.  of  children  1. 

History.  In  labor  47  hours  :  delivered  by  craniotomy  ;  the  urine  did  not  escape 
until  the  13tli  day.  Injured  seventeen  months. — Extent  of  Lesion.  A  fistula, 
directly  in  the  base  of  the  bladder,  into  which  the  finger  could  be  introduced  ; 
dense  cicatricial  tissue  on  each  side. —  Treatment.  The  failure  of  previous  opera- 
tions was  due  to  cicatricial  traction  ;  when  the  bands  were  divided  the  edges 
came  together  ;  9  sutures  used. — Duration  of  Treatment,  4  weeks  ;  Result,  cured. — 
Remarks.     Had  been  operated  on  previous  to  admission. 

134.  Admitted  Jan.  13,  1873.     Age  28.     No.  of  children  1. 

History.  In  labor  36  hours  :  attempted  to  deliver  with  forceps,  hut  failed  ;  left 
to  the  efforts  of  nature  ;  stillborn  ;  the  bladder  had  to  be  emj^tied  by  a  catheter 
for  three  months  after  her  confinement. — Extent  of  Lesion.  Laceration  entirely 
through  the  urethra,  about  one-tliird  of  an  inch  from  the  meatus  ;  the  desire  was 
frequent  to  empty  the  bladder,  and  retention  was  difficult. —  Treatment.  By  uniting 
the  two  sections  of  the  urethra  the  constant  drag  on  the  neck  of  the  bladder  was 
relieved  ;  the  only  difficulty  of  the  operation  was  in  adjusting  accurately  the  two 
portions  of  the  urethra. — Duration  of  Treatment,  4  weeks  ;  Result,  cured. 

135.  Admitted  Feh.  5,  1873.     Age   24.     Age  at  marriage  21.     No.  of  children  1. 
History.      In  labor  48  hours :  forceps  ;  stillborn  ;  large  size ;  the  bladder  had 

been  emptied  by  a  catheter  ;  two  days  after  delivery  the  urine  began  to  escape. 
Injured  eight  months. — Extent  of  Lesion.  Fistula  half  an  inch  in  diameter  near 
the  neck  of  the  bladder,  having  cicatricial  edges. —  Treatment.  Cause  of  failure 
due  to  the  cicatricial  edges  ;  these  were  removed  freely  and  brought  together  with 

5  sutures. — Duration  of  Treatment,  4  weeks. — Remarks.  Had  been  operated  on 
previous  to  admission. 


700  CASES    OF    VESICO-YAGIXAL    FISTULA 

136.  Admitted  Sept.  11,  1S73.     Age  24.     Age  at  marriage  22.     2\''o.  of  cliildreii  1. 
History.     In  labor  5  days  :  forceps  ;  stillborn  ;  1-i  pounds  ;  bladder  was  emptied  ; 

two  weeks  after  deliveiy  the  urine  began  to  be  lost.  Injured  about  two  years. — 
Extent  of  Lesion.  The  vagina  and  uterus  destroyed,  with  the  urethra  and  sub- 
pubic tissues  ;  there  remained  nothing  which  could  be  utilized  ;  the  loss  of  tissue 
unequalled  by  any  other  case  which  had  passed  under  my  observation. — Treat- 
ment. After  three  months'  preparatory  treatment  to  heal  the  parts,  the  entrance  to 
the  vagina  was  closed,  a  small  opening  being  left  below  ;  this  gave  support  to  the 
inverted  bladder,  and  was  followed  by  great  relief ;  uothing  else  could  be  done. — 
Duration  of  Treatment,  6  months  ;  Result,  improved. 

137.  Admitted  Oct.  16,  1873.     Age  35.     Age  at  marriage  29.     No.  of  children  2. 
History.     In  last  labor  48  hours  :  no  other  particulars  given. — Extent  of  Lesion. 

A  fistula,  half  an  inch  in  diameter,  situated  behind  and  close  to  the  left  ramus. — 
Treatment.  Closed  by  two  operations. — Duration  of  Treatment,  3  months  ;  Result, 
cured. — Remarks.     Operated  on  previous  to  admission. 

138.  Admitted  March  5,  1874.     Age  35.     Age  at  marriage  30.     No.  of  children  3  ; 
of  miscarriages  1. 

History.  In  second  labor  26  hours  :  completed  by  eflforts  of  nature,  stillborn  ; 
the  bladder  was  emptied  ;  urine  began  to  escape  on  the  10th  day.  Injured  about 
two  years  ;  one  child  since. — Extent  of  Lesion.  An  opening  found  at  the  bottom  of 
a  pouch  large  enough  to  admit  the  index  finger  ;  the  fundus  of  the  bladder  pro- 
lapsed through  this  opening  ;  most  of  the  posterior  cul-de-sac  was  also  lost  with 
the  uterus  ;  the  fistula  was  surrounded  by  a  puckered  mass  of  cicatricial  tissue. 
— Complications.  There  had  been  great  loss  of  tissue  and  destruction  of  the  uterus. 
— Treatment.  Closed  at  first  with  10  sutures  ;  a  portion  of  the  line  separated 
afterwards  :  closed  by  another  operation  with  7  sutures  :  unsuccessful ;  thii-d  ope- 
ration, 5  months  afterwards,  was  successful. — Duration  of  Treatment,  6  months  ; 
Result,  cured. 

139.  Admitted  March  5,  1874.     Age  25.     Age  at  marriage  23.     No.  of  children  1 ; 
of  miscarriages  1. 

History.  In  labor  26  hours  :  failed  in  applying  the  forceps  ;  delivered  by  eflforts 
of  nature  ;  child  weighed  10^  pounds,  head  very  large  ;  urine  retained  12  hours 
before  delivery,  and  had  to  be  drawn  for  2  weeks  after  ;  urine  began  to  escape  at 
end  of  3d  week. — Extent  of  Lesion.  Loss  of  the  upper  third  of  the  anterior  wall 
of  the  vagina,  with  the  anterior  lip  of  the  uterus  ;  the  opening  contracted  so  as  to 
be  reduced  to  a  size  only  large  enough  to  admit  the  finger,  and  was  situated  just 
in  front  of  the  cervix  ;  prolapse  of  the  bladder  through  the  opening. —  Treatment. 
The  remains  of  the  anterior  lip  formed  the  upper  border  of  the  fistula  and  made  a 
larger  arc  than  existed  below  ;  as  a  consequence,  the  angle  of  the  denuded  tissue 
on  the  vaginal  surface  had  to  be  carried  far  out  to  avoid  puckering  ;  10  sutures 
used. — Duration  of  Treatment,  5  weeks  ;  Result,  cured. 

140.  Admitted  Bi^T^i.  15,  1874.     Age  26.     Age  at  marriage  19.     No.  of  children  1. 
History.     In  labor  60  hours  :   forceps  attempted  ;    delivery  by  craniotomy  and 

l)lunt  hook  ;  child  weighed  15  pounds  ;  loss  of  urine  from  delivery  ;  had  puerperal 
fever  afterwards,  with  phlegmasia  dolens.  Injured  six  years. — Extent  of  Lesion. 
Loss  of  the  whole  anterior  wall  of  the  vagina,  with  partial  occlusion  of  the  canal ; 
a  large  portion  of  the  cervix  had  also  sloughed. —  Treatment.  Had  2  operations  to 
open  the  vagina,  and  3  for  closing  the  fistula. — Duration  of  Treatment,  18  months ; 
Result,  cured. 

141.  Admitted  Oct»  5,  1874.     Age  29.     Age  at  marriage  26.     No.  of  children  1. 
History.     In  labor  4  days  :  no  control  over  the  escai^e  of  tirine  after  delivery  ; 

no  further  particulars  given. — Extent  of  Lesion.  Loss  of  the  whole  anterior  wall 
of  the  vagina  and  part  of  the  anterior  lip  of  the  cervix,  with  the  cul-de-sac  filled 
with  cicatricial  bands. —  Treatment.  The  cul-de-sac  was  freely  opened  and  the  cer- 
vix divided  laterally  until  it  could  be  drawn  down  to  neck  of  the  bladder  ;  it  was 
then  united  in  this  position  by  17  sutures  ;  2  operations  afterwards  to  close  small 
openings. — Duration  of  treatment,  18  weeks ;  Result,  cured. 


RESULIING    FROM    CHILDBIRTII.  701 

142.  Admitted  Dec.  17,  1874.     Age  35,     No.  of  children  4. 

History.  In  labor  32  hours  :  delivered  by  forceps. — Extent  of  Lesion.  Anterior 
laceration  of  the  cervix  which  had  not  closed,  leaving  a  fistula  in  tiie  median 
line  extending  half  the  distance  to  the  neck  of  the  bladder. — Coiu/jlications.  Cys- 
titis when  admitted. — Treatment.  Required  four  months'  preparatory  treatment : 
one  to  free  the  cervix  from  cicatricial  tissue,  and  oiie  to  close  tlie  fistula. — Duration 
of  Treatment,  (j  months  ;  Result,  cured. — Remarks.  Had  been  operated  on  twice 
before  admission. 

143.  Admitted  Jan.  1,  1875.     Age  25.     No.  of  children  2. 

Histori/.  In  labor  98  hours  :  delivered  by  forceps  ;  loss  of  urine  since  delivery  ; 
Injured  two  years  before  admission. — Extent  of  Lesion.  Half  an  inch  below  the 
cervix  was  found  an  opening  admitting  the  finger,  the  remains  of  extensive  loss  of 
tissue  ;  the  cervix  and  cul-de-sac  were  destroyed  and  bands  ran  in  the  opposite 
direction  from  the  anterior  edge  of  the  fistula  on  to  the  posterior  wall  of  the 
vagina. —  Treatment.  These  bands  acting  in  opposite  directions  had  been  the  cause 
of  failure  ;  after  they  had  been  divided,  the  fistula  was  easily  closed  by  6  sutures. 
— Duration  of  Treatment,  4  weeks  ;  Result,  cured. — Remarks.  Had  been  operated  on 
three  times  before  admission. 

144.  Admitted  Jan.  28,  1875.     Age  33.     No.  of  children  2  ;  of  miscarriages  1. 
History.    In  last  labor  48  hours  :  breech  presentation  ;  no  control  over  the  escape 

of  urine  from  time  of  delivery. — Extent  of  Lesion.  Laceration  of  the  cervix  extend- 
ing into  the  anterior  wall  of  the  vagina,  which  partially  closed,  leaving  two  open- 
ings, one  at  the  neck  of  the  bladder,  and  the  other  in  the  median  line  one  inch 
below  the  cervix  uteri. —  Complications.     Anterior  portion  of  the  urethra  occluded. 

—  Treatment.  Each  fistula  closed  by  a  separate  operation. — Duration  of  Treatment, 
12  weeks  ;  Result,  cured. 

145.  Admitted  March  9,  1875.     Age  30.     Age  at  marriage  26.     No.  of  children  3. 
History.     In  labor  84  hours  :  twins  ;  forceps  ;  bladder  not  emjitied.    Was  injured 

in  her  first  labor. —  Treatment.  1  operation. — Duration  of  Treatment,  3  weeks  ; 
Result,  improved. — Remarks,     Had  been  operated  on  twice  previous  to  admission. 

146.  Admitted  April  21,  1875.     Age  25.     Age  at  marriage  22.     No.  of  children  1. 
History.     In  labor  33  hours  :  no  interference  ;  bladder  not  emptied. — Extent  of 

Lesion.    A  transverse  fistula,  close  to  the  cervix  uteri,  about  half  an  inch  in  length. 

—  Treatment.  1  operation  ;  9  sutures  ;  removed  the  10th  day. — Duration  of  Treat- 
ment, 4  weeks  ;  Result,  cured. — Remarks.  Had  been  operated  on  three  times  pre- 
vious to  admission. 

147.  Admitted  A^r\\  "21,  1875.     Age  25.     Age  at  marriage  21.     No.  of  children  1. 
History.     In  last  labor  15  hours  :  delivered  with  forceps. — Extent  of  Lesion.     A 

fistula  at  the  neck  of  the  bladder  nearly  an  inch  in  diameter,  a  result  of  a  loss  of 
one-third  of  the  lower  portion  of  the  anterior  wall. —  Treatment.  1  operation  ;  11 
sutures  ;  removed  on  the  12th  day. — Duration  of  Treatment,  3  weeks  ;  Result, 
cured. 

148.  Admitted  Sept.  18,  1875.     Age  25.     Age  at  marriage  20.     No.  of  children  2. 
Llistory.     First  labor,  lasting  8  days,  terminated  by  forceps  ;  stillborn  ;  thinks 

the  bladder  was  emptied  ;  urine  began  to  escape  from  delivery  ;  in  bed  2  months. 
Injured  4  years  ;  second  child  born  one  year  after. — Extent  of  Lesion.  Fistula  at 
the  neck  of  the  bladder,  an  inch  long  and  half  an  inch  wide,  extending  from  the 
left  of  the  median  line  to  behind  the  right  ramus  ;  transverse  bands  from  the 
edges  of  the  fistula  ran  upon  each  side  of  the  vagina,  more  on  the  left ;  these 
caused  the  anterior  lip  to  somewhat  overlap  the  fistula  and  to  form  a  sulcus  on 
each  side  of  the  opening. — Complications.  Laceration  of  the  cervix  from  before 
backward  and  on  the  left  side  ;  perineum  was  extensively  lacerated. —  Treatment. 
After  division  of  the  bands,  the  fistula  became  much  larger  ;  closed  by  13  sutures  ; 
kept  dry  for  several  days  after  removing  the  sutures  ;  second  operation  to  close 
a  new  opening,  using  6  sutures  ;  again  dry  for  several  days,  when  an  opening  was 
found  in  the  first  line  ;  this  was  closed  with  7  sutures. — Duration  of  Treatment,  6 
months  ;  Result,  cured. — Remarks.  Had  been  operated  on  once  previous  to 
admission. 


702  CASES    OF    RECTO-VAGINAL    FISTULA 

149.  Admitted  Sept.  18,  1875.     Age  35.     Age  at  marriage  32.     No.  of  children  2. 

Historij.  In  labor  48  hours  :  ergot,  chloroform ;  forceps  ;  stillborn  ;  urine  lost 
from  the  2d  day.  Injured  ten  months. — Extent  of  Lesion.  Laceration  through  the 
cervix  from  before  backwards  ;  that  through  the  posterior  lip  extended  into  the 
cul-de-sac  and  healed,  leaving  a  mass  of  cicatricial  tissue  ;  that  through  the  ante- 
rior lip  extended  in  the  median  line  along  the  base  to  the  neck  of  the  bladder  ; 
the  bands  behind  the  uterus  then  drew  the  sides  of  the  fistula  backward  so  as  to 
form  a  transverse  opening  just  in  front  of  the  cervix  ;  the  tear  through  the  ante- 
rior lip  did  not  close. —  Treatment.  The  bands  were  all  divided  so  as  to  free  the 
edges  of  the  fistula,  when  it  was  closed  in  the  median  line  and  united  with  3 
sutures  in  the  cervix  and  7  in  the  fistula. — Duration  of  Treatment,  4  weeks  ;  Result, 
cured. 

l^Q.  Admitted  Sept.  23,  1875.  Aga  4A.  Age  at  marriage  23.  No.  of  children  10. 
History.  In  labor  24  hours  :  ergot ;  stillborn  ;  very  large  child  ;  escape  of  urine 
from  time  of  delivery.  Injured  ten  months  previous  to  admission. — Extent  of 
Lesion.  Loss  of  the  whole  base  of  the  bladder,  the  neck  of  the  bladder,  and  one- 
third  of  the  urethra  ;  the  vagina  terminated  along  the  posterior  edge  of  the  fis- 
tula ;  it  was  found  that  the  posterior  wall  of  the  vagina  had  united  to  the  edge  of 
the  fistula,  thus  shutting  up  the  cervix  and  vagina  beyond. — Complications.  Pro- 
lapse of  the  whole  bladder  through  the  fistula  ;  the  perineum  had  been  extensively 
torn. — Treatment.  Through  a  small  opening  a  j^robe  passed,  demonstrating  the 
septum  ;  when  this  had  been  divided,  the  edges  of  the  fistula  could  be  brought 
together,  which  was  done  with  15  sutures  ;  small  opening  left ;  closed  by  6  sutures  ; 
opening  again  made  by  the  patient  in  attempting  to  introduce  the  catheter  herself; 
closed  by  6  sutures. — Duration  of  Treatment,  5  months  ;  Result,  cured. 

151.  Admitted  Nov.  9,  1875.     Age  39.     No.  of  children  4  ;  of  miscarriages  5. 

History.  Time  not  given  ;  had  no  labor-pains  after  rupture  of  the  menibranes  ; 
ergot;  forcej)s  ;  stillborn;  loss  of  urine  from  the  time  of  delivery.  Injured  five 
years  ;  not  pregnant  since. — Extent  of  Lesion.  Loss  of  the  base  of  the  bladder, 
including  the  neck  of  the  bladder  and  upj)er  part  of  the  urethra ;  the  opening  was 
an  inch  wide  and  extended  from  ramus  to  ramus  ;  mouth  of  the  right  ureter 
exposed ;  uterus  retroverted,  with  the  cervix  projecting  into  the  bladder  ;  the 
posterior  wall  of  the  bladder  had  become  adherent  over  the  posterior  lip  of  the 
uterus  up  to  the  os. —  Complications.  Prolapse  of  the  fundus  of  the  bladder  through 
the  fistula. —  Treatment.  An  attempt  had  been  made  to  close  the  fistula  and 
restore  the  neck  of  the  bladder,  and  this  had  led  to  an  adhesion  of  the  fundus  of 
the  bladder  to  the  cervix  ;  this  could  not  now  be  dissected  off,  and  nothing  could  be 
done  but  close  the  remaining  opening ;  this  was  done  with  14  sutures. — Duration 
of  Treatment,  4  weeks  ;  Result,  cured. — Remarks.  Had  been  operated  on  four  times 
previous  to  admission. 

1^2.  Admitted  Dec.  9,  1875.     AgQ  32.     Age  at  marriage  20.     No.  of  children  8. 

History.  In  labor  37  hours  :  embryotomy ;  bladder  not  emptied  ;  loss  of  urino 
from  the  time  of  delivery  ;  confined  to  bed  five  months. — Complications.  Partial 
atresia  of  the  vagina  at  the  depth  of  an  inch,  through  which  can  be  seen  the  pro- 
lapsed fundus  of  the  bladder. —  Treatment.     2  operations. 

UZ.  Admitted  .Jan.  3,  1876.     Aga  25.     No.  of  children  1. 

•  History.  In  labor  44  houi's  :  forceps  ;  urine  began  to  escape  3  weeks  after 
delivery. — Extent  of  Lesion.  A  fistula  but  a  quarter  of  an  inch  in  diameter,  situ- 
ated in  the  median  line  and  in  front  of  the  neck  of  the  bladder  ;  there  had  been 
great  loss  of  tissue,  and  the  opening  was  surrounded  by  cicatricial  tissue. —  Treat- 
ment. 1  operation  ;  the  cicatricial  edges  were  freely  rimioved,  and  the  surfaces 
united  by  7  sutures. — Duration  of  Treatment,  25  days  ;  Result,  cured. 

154.  Admitted  Feb.  4,  187G.     Age  46.     Age  at  marriage  22.     No.  of  children  3  ;  of 
miscarriages  2, 
Extent  of  Lesion.     Fistula  quite  small,  situated  in  the  median  line  at  the  junc- 
tion of  the  base  and  neck  of  the  bladder. —  Treatment.     3  operations. — Duration  of 
Treatment,  3  months  ;  Result,  cured. 


RESULTING    FROM    CHILDBIRTH.  703 

155.  Admitted  May  10,  1S7G.     Age  35.     Age  at  marriage  27.     No.  of  children  1 
Ilistori/.     In  hil)()r  12  hours  :  delivered  with  forceps. — Extent  of  Lesion.     Loss  of 

the  hase  of  tlie  hladder  and  a  portion  of  the  urethra. 

156.  Admitted  Oct.  9,  1876.     Age  26.     Age  at  marriage  22.     No.  of  children  2. 
Ilistory.     In   last  labor  48  hours :  delivered  by  forceps.     Injured  three  months 

previous  to  admission.. — Extent  of  Lesion.  Fistula  in  the  neck  of  the  bladder. — 
Complications.  Extensive  laceration  of  the  perineum. —  Treatment.  1  operation  ; 
18  sutures  ;  removed  11th  day. — Duration  of  'Treatment,  14  weeks  ;  Result,  cured. 
— Remarks.     Had  been  operated  on  previous  to  admission. 

157.  Admitted  Oct.  17,  1876.     Age  36.     Age  at  marriage  17.     No.  of  children  7. 
History.     In  last  labor   33  hours  :  delivered  by  the  efforts  of  nature ;    loss  of 

urine  since  delivery.  Injured  four  years  previous  to  admission. — Extent  of  Lesion. 
Laceration  of  the  anterior  lip  of  the  uterus  through  the  median  line,  which  closed 
leaving  a  fistula  into  tlie  bladder  just  in  front  of  the  cervix. —  Treatment.  1  ope- 
ration.— Duration  of  Treatment,  8  weeks  ;   Result,  cured. 

158.  Admitted  Oct.  28,  1876.     Age  24.     Age  at  marriage  20.     No.  of  children  1. 
Historij.     In  labor  20  hours  :  head  impacted  13  hours  ;  embryotomy  ;  bladder 

not  emptied  during  labor.  Injured  three  years. — Extent  of  Lesion.  A  fistula 
quarter  of  an  inch  in  diameter  close  behind  the  left  ramus. —  Complications.  Lace- 
ration of  the  perineum. 

159.  Admitted  Oct.  2,  1877.     Age  47.     Age  at  marriage  32.     No.  of  children  3  ;  of 
miscarriages  2. 

History.  With  the  first  child. — Extent  of  Lesion.  Fistula  quite  small,  at  the 
neck  of  the  bladder. —  Treatment.  2  operations. — Duration  of  Treatment,  7  weeks  ; 
Result,  cured. — Remarks.  Had  been  ojierated  on  several  times  previous  to  admis- 
sion, but  the  fistula  opened  by  traction. 

160.  Admitted  Nov.  19,  1877.  Age  30.  Age  at  marriage  28.  No.  of  children  1. 
Historij.  In  labor  24  hours  :  delivered  with  forceps.  Injured  eight  months  pre- 
vious to  admission. — Extent  of  Lesion.  An  opening  midway  between  the  neck  of 
the  bladder  and  cervix  uteri,  an  inch  in  diameter,  with  a  prolapse  of  the  bladder 
through  it. —  Treatment.  1  operation  ;  11  sutures  ;  removed  on  the  11th  day. — 
Duration  of  Treatment,  4  weeks  ;  Result,  cured. 

161.  Admitted  Dec.  17,  1877.     Age  27.     No.  of  children  2, 

History.  In  last  labor  48  hours  :  delivered  with  forceps  ;  loss  of  urine  from  the 
second  day  after  delivery. — Extent  of  Lesion.  The  cervix  had  been  turned  into 
the  bladder,  leaving  a  small  and  tortuous  opening  in  the  midst  of  cicatricial  tissue. 
— Remarks.     Had  been  operated  on  previous  to  admission. 

RECTO-VAGINAL  FISTULA. 

162  (lxix.).     Admitted  Nov.  13,   1862.     Age   33.     Age  at  marriage   27.     No.  of 
children  1. 

History.  In  labor  140  hours  :  delivered  by  forceps  ;  stillborn ;  no  stool  was 
thrown  off;  feces  passed  from  the  vagina  three  days  after  delivery. — Extent  of 
Lesion.  An  opening  into  the  rectum  was  to  the  left  of  the  median  line,  half  an 
inch  beyond  the  fourchette,  in  the  shape  of  a  half  circle,  and  scarcely  large 
enough  to  admit  the  end  of  the  index  finger. —  Treatment.  In  consequence  of  its 
shape  and  position,  it  was  closed  by  dissecting  off  a  flap  from  the  lateral  wall, 
which  was  folded  down  over  the  fistula,  so  that  when  secured  the  vaginal  tissue 
had  been  turned  into  the  rectum  ;  9  sutures  were  used. — Duration  of  Treatment,  4 
weeks  ;  Result,  cured. 

163  (lxvi.).     Jc/mi«ecZ  Jan.  3, 1864.     Age  39.     Age  at  marriage  14.     No.  of  child- 
ren 8. 

History.  Eighth  pregnancy :  84  hours  in  labor  ;  delivered  by  forceps  ;  ergot 
had  been  administered  without  effect,  for  the  head  was  on  the  perineum  36  hours  ; 


704  CASES    OF    RECTO-VAGTNAL    FISTULA. 

at  the  end  of  2d  week  a  slough  came  away,  followed  hy  passage  of  feces  from  the 
vagina. — Extent  of  Lesion.  A  rectal  fistula,  crescentic  in  shape  with  its  cornua 
towards  the  cul-de-sac,  extended  from  half  an  inch  beyond  the  fourchette  to 
the  cervix  uteri ;  in  the  centre  the  edges  were  about  three-quarters  of  an  inch 
apart,  and  the  opening  large  enough  to  introduce  two  fingers,  but  there  had  been 
evidently  a  great  loss  of  tissue  from  the  fact  that  the  edges  were  tense  and  cica- 
tricial in  character. — Complications.  A  vesico-vaginal  fistula.  See  Case  17. — 
Treatment.  As  the  edges  were  denuded,  the  surface  was  increased  in  width  by 
extending  it  around  on  the  vaginal  surface,  and  these  were  brought  together  by  9 
sutures  ;  sutures  removed  on  the  11th  day  ;  union  perfect ;  after  a  few  days  the 
parts  gradually  separated  to  the  original  condition  ;  a  year  after,  closed  the  open- 
ing with  8  sutures  ;  bands  were  freely  divided,  and  the  posterior  lip  split  to  increase 
the  surfaces  ;  a  small  opening  was  left,  which  was  closed  afterwards  with  4  sutures. 
— Duration  of  Treatment,  4  months  ;  Result,  cured. 

164.  Admitted  Feb.  2,  1864.     Age  26.     Age  at  marriage  24.     No.  of  children  1. 

History.  In  labor  5  days  :  delivered  with  forceps. — Extent  of  Lesion.  Rectal 
fistula,  nearly  an  inch  in  diameter,  just  beyond  the  sphincter  and  in  the  midst  of 
dense  cicatricial  tissue. — Complications.  Vesico-vaginal  fistula.  See  Case  25. — 
Treatment.  Closed  by  3  operations  ;  from  the  character  of  the  tissue,  the  edges 
would  separate  after  removal  of  the  sutures. — Duration  of  Treatment,  not  stated  ; 
Result,  cured. 

165  (lxviii.).  Admitted  May  10,  1864.  Age  27.  Age  at  marriage  19.  No.  of 
children  1. 
History.  In  labor  65  hoiirs  :  delivered  by  the  efforts  of  nature  ;  two  weeks 
after  delivery  sloughs  passed,  when  control  over  contents  of  the  rectum  was  lost. 
— Extent  of  Lesion.  An  opening  situated  in  the  median  line,  about  three-quarters 
of  an  inch  beyond  the  fourchette  ;  it  was  circular  in  shape,  about  an  inch  in 
diameter  at  the  rectal  surface,  and  with  i;eceding  edges,  which  were  thin  and  tense. 
— Complications.  A  small  vesico-vaginal  fistula.  See  Case  26. — Treatment.  Two 
parallel  incisions  were  made  in  the  axis  of  the  vagina,  through  cieatricial  tissue, 
to  free  its  edges ;  first  operation  failed  on  account  of  the  vesical  fistula,  through 
which  the  urine  escaped  after  traction  was  made  on  closing  the  rectal  opening. — 
Duration  of  Treatment,  2  months  ;  Result,  cured. 

166.  Admitted  March  15,  1865.  Age  27.  Age  at  marriage  25.  No.  of  children  1. 
History.  In  labor  24  hours  :  craniotomy. — Extent  of  Lesion.  Large  transverse 
fistula  ;  vagina  much  contracted  by  cicatricial  bands. —  Treatment.  1  operation. — 
Duration  of  Treatment,  3  months  ;  Result,  improved. — Remarks.  Did  not  return  to 
have  a  small  opening  closed. 

167  (lxvii.).  Admitted  March  24,  1865.  Ago.  23.  Age  at  marriage  21.  No.  of 
children  1. 
History.  Time  of  labor  unknown  :  delivered  by  craniotomy  a  year  previous  to 
admission. — Extent  of  Lesion.  A  rectal  fistula  existed  behind  a  fold  of  the  poste- 
rior wall  of  the  vagina,  formed  by  contraction  of  cicatricial  tissue  around  the 
outlet ;  this  band  could  not  be  divided  for  the  puspose  of  exposing  the  rectal 
opening,  as  its  presence  afforded  a  retentive  power  to  the  urethra  ;  the  cul-de-sac 
had  been  destroyed,  and  tlie  neck  of  the  uterus  lost. — Complications.  A  vesico- 
vaginal fistula.  See  Case  46. —  Treatment.  The  fistula  was  closed  by  one  opera- 
tion, performed  almost  entirely  by  the  sense  of  touch,  as  the  opening  could  not  be 
brought  into  view  ;  13  sutures  used  ;  for  a  few  days  there  was  an  escape  of  flatus, 
but  this  soon  ceased  when  the  parts  contracted. — Duration  of  Treatment,  3  weeks  ; 
Result,  cured. 

168.  Admitted  Dec.  8,  1865.     Age  23.     Age  at  marriage  19.     No.  of  children  1. 

History.  In  labor  32  hours:  naturaL — Extent  of  Lesion.  Fistula,  half  an  inch 
in  diameter,  situated  just  bi'yond  tlie  sphincter  ani. —  Treatment.  1  operation  ;  14 
sutures;  removed  9th  day;  no  union. — Duration  of  Treatment,  4  weyks ;  Result, 
not  improved. — Remarks.     Would  not  submit  to  a  second  operation. 


CASES    OF    VESICO-VAGIXAL    FISTULA.  705 

169.  Admitted  Nov.  17,  1SG6.     Aa;e  24.     Age  at  marriage  22.     No.  of  children  1. 
JJislori/.     In    labor   4   days :    delivered    with    forceps. — Extent   of  Lesion.     The 

original  condition  was  an  extensive  laceration  through  the  sphincter  ani  and 
recto-vaginal  septum ;  this  closed  below,  leaving  a  fistula  above  between  the 
rectum  and  vagina. — Complications.  A  vesico-vaginal  fistula.  See  Case  ."ifj. — 
Treatment.  The  united  portion  was  divided  with  a  pair  of  scissors,  and  the  whole 
brought  together  as  if  for  laceration  of  the  perineum. — Duration  of  Treatment,  3 
weeks ;  Result,  cured. 

170.  Admitted  Oct.  19,  1869.     Age  27.     Age  at  marriage  26.     No.  of  children  1. 
lUstortj.     Labor  lasted  5  hours,  and  was  natural  in  every  respect :  on  the  day 

after  delivery  noticed  the  escape  of  flatus  by  the  vagina. — Extent  of  Lesion.  The 
listula  extended  obliquely  from  the  sphincter  muscle  to  the  left,  and  was  an  inch 
in  length. —  Treatment.  Closed  by  one  operation. — Duration  of  Treatment,  3  months  ; 
Result,  cured. 

171.  Admitted  Jan.  9,  1873.     Age  26.     No.  of  children  1. 

History.  In  labor  24  hours  :  terminated  by  eflbrts  of  nature  ;  child  stillborn. — 
Extent  of  Lesion.  Fistula  just  beyond  the spliincter  ani. —  Complications.  A  vesico- 
vaginal fistula.  See  Case  130. —  Treatment.  1  operation  ;  5  sutures  ;  removed  on 
the  8th  day. — Duration  of  Treatment,  3  weeks  :  Result,  cured. 


VESICO-VAGINAL  FISTULA. 

II — From  other  causes  than  Childbirth. 

172  (lxx.).  Admitted  1i^ or.  1S64.     Age  36.     Social  relation,  married.    Age  at  mar- 
riage 18.     No.  of  children  10. 

History.  In  Nov.  1862,  was  delivered,  after  a  labor  of  three  days  ;  shortly 
after,  an  abscess  burst  into  the  vagina,  followed  by  an  involuntary  escape  of  the 
urine  ;  nine  months  previous  to  admission,  she  had  been  delivered  of  her  tenth 
child. — Local  Condition.  Abscess  opening  into  the  bladder  ;  from  an  opening  into 
the  vagina,  situated  about  half  an  inch  behind  the  neck  of  the  bladder,  the  urine 
all  escaped  ;  a  sound  was  passed  along  the  sinus  until  it  reached  the  side  of  the 
uterus,  when  its  point  passed  into  the  bladder. —  Treatment.  The  point  of  a  pair 
of  scissors,  following  a  probe,  was  introduced  into  the  sinus  and  its  course  divided 
up  for  some  two  inches  until  the  opening  into  the  bladder  had  been  reached  ;  the 
edges  of  the  opening  into  the  bladder  were  then  freshened,  the  tract  of  the  sinus 
removed  in  one  strip  by  scissors,  and  the  whole  line  closed  by  11  interrupted 
sutures. — Duration  of  Treatment,  4  weeks  ;  Result,  cured. 

173  (lxxi.).  Admitted  "May  19,  186Q.  Age  41.  Social  relation,  single. 
History.  Two  years  before  began  to  have  incontinence  of  urine  ;  her  physi- 
cian removed  a  corroded  "horseshoe"  pessary,  one  limb  of  which  had  entered 
the  bladder  ;  she  had  not  been  examined  for  five  years,  and  did  not  know  of  its 
existence  in  the  vagina. — Local  Condition.  Opening  into  the  bladder  was  situated 
behind  the  left  ramus,  at  the  bottom  of  the  sulcus  formed  between  the  lateral  wall 
and  the  base  of  the  bladder  ;  a  No.  12  bougie  could  be  passed  through  the  opening, 
the  edges  of  which  were  thin  and  tense,  being  formed  entirely  of  cicatricial  tissue. 
—  Treatment.  She  had  been  operated  on  by  her  physician,  and  the  failure  was  due 
to  the  character  of  tissue  ;  it  was  closed  with  9  sutures  by  doubling  down  a  fold 
of  the  lateral  wall  over  on  to  the  base  of  the  bladder,  so  as  to  inclose  the  fistula 
in  a  pouch  below. — Duration  of  Treatment,  4  weeks  ;  Result,  cured. — Remarks.  Had 
been  operated  on  previous  to  admission. 

174  (lxxii.).     Admitted  Dec.  8,  1866.     Age  25.     Social  relation,  single. 
History.     Some  20  months  previous  to  admission  she  was  accidentally  wounded 

by  a  ball  from  a  revolver. — Local  Condition.  It  was  found  that  the  ball  had  entered 
the  right  thigh  and  passed  from  the  vagina  through  the  bladder  into  the  abdominal 
cavity  and  lodged  above  the  crest  of  the  ilium. —  Treatment.  No  union  after  the 
first  and  second  operations,  on  account  of  cicatricial  tissue  and  the  occurrence  of 
cystitis  ;  finally,  this  tissue  was  freely  removed,  and  the  third  operation  was  sue- 
45 


706  CASES    OF    VESICO-VAGINAL    FISTULA 

cessful. — Duration  of  Treatment,   6  months  ;   Result,  cured. — Remarks.     Had  been 
operated  on  previous  to  admission. 

175.  Admitted  Oct.  lb,  \^61.     Age  34.     Social  relation,  married.     Age  at  marriage 
26.     No.  of  children  4. 

History.  Had  a  glass  syringe  break  in  the  vagina  about  5  years  previous  to 
admission  ;  loss  of  urine  immediately,  which  was  increased  by  the  passage  of  a 
slough  a  short  time  afterwards. — Local  Condition.  An  oblique  fistula,  half  an  inch 
in  length,  was  found  at  the  neck  of  the  bladder  in  the  midst  of  cicatricial  tissue  ; 
all  the  evidences  of  secondary  syphilis  were  detected. — Tieatment.  After  careful 
constitutional  treatment,  the  fistula  was  closed  with  10  sutures,  care  having  been 
taken  to  remove  all  the  cicatricial  tissue  ;  the  sutures  were  removed  on  the  12th 
day,  and  no  union  had  taken  place. — Result,  not  improved. — Remarks.  The 
syphilitic  condition  interfered  with  the  process  of  healing. 

176.  Admitted  Nov.  3,  1868.     Age  34.     Social  relation,  married.     Age  at  marriage 
21.     No.  of  children  4. 

History.  Fistula  caused  by  syphilitic  sloughing. — Local  Condition.  Fistula  near 
the  neck  of  the  bladder,  with  syphilitic  condylomata. — Treatment.  Was  placed 
for  5  months  on  constitutional  treatment,  and  then  the  fistula  closed  by  7  sutures, 
which  were  removed  on  the  8th  day. — Duration  of  Treatment,  6  months ;  Residt, 
cured. — Remarks.  The  only  case  in  which  union  was  obtained  where  the  patient 
had  sufiered  from  syphilis. 

177.  Admitted  Oct.  16,  1868.     Age  19.     Social  relation,  married.     Age  at  marriage 

18.  Sterile. 

History.  An  operation  had  been  attempted  for  the  relief  of  "vaginismus." — 
Local  Condition.  A  small  opening  found  across  the  neck  of  the  bladder. — Treat- 
ment. 2  operations  :  one  to  open  the  vaginal  outlet,  and  the  other  to  close  the  fis- 
tula.— Duration  of  Treatment,  5  weeks  ;  Result,  cured. — Remarks.  Delivered  of  one 
child,  weighing  9  pounds,  Feb.  1SG9. 

178.  Admitted  Dec.  13,  1870.     Age  22.     Social  relation,  single. 

History.  Congenital  absence  of  the  vagina  ;  an  attempt  had  been  made  to  reach 
the  uterus. — Local  Condition.  The  urethra  in  front  of  the  neck  of  the  bladder  had 
been  entered  and  the  neck  divided,  so  that  the  finger  entered  directly  into  the 
bladder. —  Treatment.  An  artificial  vagina  was  made  and  the  fistula  closed  ;  the 
uterus  afterwards  developed. — Result,  cured. — Remarks.  See  history  of  this  case 
under  the  head  of  Congenital  Absence  of  the  Vagina. 

179.  Admitted  5 \\n.Q  6,  1871.     Age  62.     Social  relation,  married.     Age  at  marriage 

19.  No.  of  children  5. 

History.  Her  last  child  was  20  years  of  age  ;  change  of  life  at  47  ;  had  been 
well  until  three  years  previoiis  to  admission  ;  without  any  known  cause,  she 
began  to  sufl'er  from  irritation  of  the  bladder  ;  in  the  preceding  January  the 
bladder  had  been  opened,  but  without  relief. — Local  Condition.  An  attempt  had 
been  made  to  open  the  bladder  ;  a  portion  of  the  urethra  and  the  neck  of  the 
bladder  had  been  laid  open  ;  the  consequence  was  that  the  superabundant  tissue 
at  the  neck  of  the  bladder  crowded  into  the  opening  as  a  plug  and  caused  great 
distress  ;  there  was  no  cystitis. —  Treatment.  The  tissue  projecting  through  the 
opening  was  first  removed  by  a  double  ligature  ;  after  its  removal  she  was 
allowed  to  return  home  for  six  months,  during  which  time  the  urine  had  a  free 
exit ;  the  fistula  was  then  closed  with  6  sutures  ;  successful ;  it  was  supposed 
that  a  small  fissure  had  existed  at  the  neck  of  the  bladder,  causing  the  irritation. 
— Duration  of  Treatment,  2  months  ;  Result,  cured. 

180.  Admitted   Sept.  18,  1877.     Age  24.     Social   relation,  married.     Age  at  mar- 
riage'20. 

History.  Fistula  accidentally  made  during  the  operation  for  atresia  vaginje 
rcisulting  from  childbirth. — Local  Condition.  The  vagina  was  constricted  from  a 
slough  at  the  depth  of  an  inch  ;  just  above  this  point  the  false  opening  extended 
to  the  cervix  and  entered  tlie  bladder. —  Treatment.  Closed  by  1  operation,  and 
th(i  sutures  were  removed  on  the  9th  day. — Duration  of  Treatment,  3  weeks  ;  Result, 
cured. 


FOR  TUE  REMOVAL  OF  STOXE.  TC7 

181.  Admitted  Sept.  27,  1S77.     Age  40.     Social  relation,  single. 

History.  Witliout  known  cause,  began  to  sulTer  from  cystitis  six  years  previous 
to  admission  ;  two  years  after  had  an  opening  made  in  the  base  of  the  bladder, 
with  entire  relief;  but  tlie  opening  was  closed  too  soon,  and  the  disease  returned  ; 
an  attempt  was  made  to  dilate  the  urethra,  which  resulted  in  laceration,  with  no 
retentive  p  jwei  afterwards. — Local  Condition.  Tlie  urethra  was  laceratctd  backward 
from  tile  outlet  for  half  an  inch  ;  with  an  irritable  and  contracted  bladder  ;  from  the 
thickening  and  contracting  of  the  base  of  the  bladder,  the  urethra  was  drawn  back- 
ward and  was  in  the  same  condition  as  if  an  opening  had  been  made  through  the  base 
of  the  bladder. —  Triatment.  Examination  gave  evidence  of  an  irritable  Idadder,  but 
none  of  kidney  disease  ;  an  opening  was  made  in  the  bladder  and  the  urethra  length- 
ened out  half  an  inch  ;  second  day  after  operation,  irritation  of  the  bladder  came  on 
with  microscopic  evidence  of  kidney  disease  ;  on  the  sixth  day  died  from  uremic 
poisoning. — Duration  of  Treatment,  (j  weeks  ;  liesult,  died. — Remarks.  Ursemic  poison- 
ing was  hastened  by  the  use  of  ether ;  with  the  existing  disease  the  organs  were 
placed  above  the  secreting  point  in  its  elimination. 


Ill For  the  Removal  of  Stone. 

182  (i.).  Admitted  k^vi\,l^QQ.  Age  46.  Social  relation,  married.  Age  at  mar- 
riage 18.  No.  of  children  15. 
History.  Eighteen  months  after  closing  a  vesico-vaginal  fistula,  resulting  from 
an  antero-posterior  laceration  of  the  cervix,  a  stone  was  removed  from  the  bladder. 
— Local  Condition.  Large  stone  in  the  bladder. — Treatment.  The  stone  was  removed 
through  an  opening  made  in  the  base  of  the  bladder  ;  in  consequence  of  the  pre- 
vious loss  of  urine  and  size  of  the  stone,  it  was  first  crushed  through  this  opening, 
the  large  pieces  removed  with  a  scoop,  and  the  bladder  washed  out ;  three  months 
afterwards,  the  opening  was  closed  with.  8  sutures. — Duration  of  Treatment,  4  months; 
Result,  cured. 

183.  Admitted  M?Lj  IZ,  1^10.     Age  40.     Social  relation,  married. 

History.  Operated  on  by  Dr.  Sims  in  1860,  by  which  the  neck  of  the  uterus 
was  turned  into  the  bladder  ;  remained  well  for  eight  years  afterwards,  when 
symptoms  of  cystitis  occurred,  and  her  condition  was  a  miserable  one  at  the  time 
of  admission. — Local  Condition.  By  means  of  the  endoscope,  it  was  found  that  the 
mucous  membrane  of  the  bladder  was  extensively  ulcerated  ;  until  an  anaesthetic 
was  given,  it  was  not  known  that  an  encysted  stone  existed  on  the  left  side  of  the 
bladder. —  Treatment.  The  stone  was  removed  through  an  opening  made  in  the 
base  of  the  bladder,  and  for  five  months  the  bladder  was  kept  empty  and  fre- 
quently washed  out ;  the  fistula  was  then  closed  with  6  sutures. — Duration  of 
Treatment,  3  months  ;  Result,  cured. — Remarks.  2  years  after  the  operation  there 
had  been  no  return  of  the  cystitis. 

184.  Admitted  Sept.  24,  1872.  Social  relation,  married.  No.  of  children  2. 
History.  Had  had  a  small  fistula  behind  each  ramus  closed  by  different  opera- 
tions.— Local  Condition.  After  the  last  opening  had  been  closed,  irritation  of  the 
bladder  came  on,  which  was  thought  due  to  the  use  of  the  catheter  ;  after  a  care- 
ful examination,  an  encysted  stone  was  found. —  Treatment.  Removed  through  an 
artificial  fistula,  and  the  bladder  left  empty  for  three  months,  when  the  opening 
was  closed  ;  in  the  interval  she  had  returned  home. — Duration  of  Treatment,  2 
months  ;  Result,  cured. — Remarks.  An  ordinary  toilet  pin  was  found  to  have  been 
tlie  nucleus. 

185.  Admitted  Sept.  18,  1873.     Age  39.     Social  relation,  married.     No.  of  child- 
ren 6. 

History.  A  stone  had  been  removed  from  the  bladder  nine  months  before  admis- 
sion.— Local  Condition.  Either  as  a  rc^sult  of  the  last  labor  or  from  a  slough  fol- 
lowing the  removal  cf  the  stone,  atresia  of  the  vagina  existed  ;  the  opening  was 
small  and  involved  the  neck  of  the  bladder,  as  well  as  a  portion  of  the  urethra, 
with  a  i^rolapse  of  the  mucous  membrane  of  the  bladder. —  Treatment.  5  operations, 
extending  over  a  period  of  two  years,  for  opening  the  vagina  and  closing  the  fis- 
tula ;  when  last  seen,  it  was   supposed  that  the  partial  loss  of  urine  was  due  to 


708  CASES    OF    VESICO-VAGINAL    FISTULA 

traction  of  the  cicatricial  tissue  on  the  urethra,  as  no  opening  could  be  found  ;  she 
■was  to  return  in  case  the  loss  continued. — Result,  improved. — Remarks.  Slie 
never  returned  to  the  Hospital,  and  nothing  was  known  of  her  after-condition. 

186.  Admitted  Oct.  31,  1874.     Social  relation,  married. 

History.  After  the  closure  of  a  vesico-vaginal  fistula,  the  patient  began  to  have 
irritation  of  the  bladder,  which  increased  to  such  a  degree  as  to  render  her  incapa- 
ble of  following  any  occupation. — Local  Condition.  No  examination  could  be  made 
until  ether  had  been  administered  ;  the  sound  detected  a  hard  mass  projecting 
into  the  cavity  of  the  bladder,  which  was  situated  in  the  median  line  near  the 
cervix. —  Treatment.  With  a  sound  in  the  bladder  as  a  guide,  by  means  of  scissors 
the  mass  was  cut  down  upon  ;  it  was  found  tliat  a  suture  had  been  cut  oif  close  to 
the  twist  and  left  in  the  tissues  ;  the  loop  had  gradually  worked  around  until  the 
two  ends  of  the  wire  projected  into  the  bladder  ;  on  these  points  a  phosphatic 
deposit  had  taken  place. — Result,  cured. 

187.  Admitted  March  7,  1876.     Age   42.     Social  relation,  married.     No.  of  child- 
ren 6. 

History.  In  January,  1869,  she  had  a  vesico-vaginal  fistula  closed  which  had 
resulted  from  a  laceration  of  the  cervix  through  the  anterior  lip  ;  tlie  stone  was 
removed  in  January,  1873,  since  which  time  several  attempts  had  been  made  to 
close  the  fistula  and  without  success. — Local  Condition.  A  vesico-vaginal  fistula 
remaining  after  the  removal  of  stone  from  the  bladder  ;  the  edges  were  cicatricial 
from  the  frequent  freshening  of  the  surfaces  for  operation. —  Treatment.  Closed  by 
2  operations,  the  first  not  being  entirely  successful. — Duration  of  Treatment,  7 
weeks  ;  Result,  cured. — Remarks.  Had  been  operated  on  several  times  previous  to 
admission. 

188.  Admitted  Oct.  19,  1867.     Age  43.     Social  relation,  married. 

History.  A  stone  had  been  removed  from  the  bladder  about  four  years  previous 
to  admission  ;  several  attempts  had  been  made  to  close  the  opening. — Local  Con- 
dition. An  opening  in  the  base  of  the  bladder  remaining  after  the  removal  of  a 
stone. —  Treatment.  Closed  by  one  operation. — Duration  of  Treatment,  3  weeks; 
Result,  cured. — Remarks.     Had  been  operated  on  previous  to  admission. 


IV, — For  the  Relief  of  Cystitis. 

189.  Admitted  Nov.  8,  1867.     Age  35.     Social  relation,  married.     Age  at  marriage 
17.     No.  of  children  1. 

History.  Three  years  before  admission  she  had  a  fall ;  disease  of  the  bladder 
afterwards. — Local  Condition.  Uterus  retroverted  ;  she  had  had  cellulitis  ;  walls 
of  the  bladder  were  thickened,  with  all  the  symptoms  of  cellulitis. —  Treatment, 
After  seven  months'  local  treatment,  and  with  but  little  benefit,  an  artificial  open- 
ing was  made  between  the  vagina  and  bladder  ;  it  was  left  open  for  18  months, 
but  no  union  took  place  in  consequence  of  its  cicatricial  edges  ;  5  months  after, 
the  opening  was  again  closed  with  7  sutures. — Duration  of  Treatment,  32  months  ; 
Result,  cured. 

190.  Admitted  June  10,  1868.     Age  27.     Social  relation,  single. 

History.  Two  years  before  admission  patient  had  received  a  blow  against  the 
abdomen,  which  was  followed  by  irritation  of  the  bladder ;  she  then  took  cold' 
which  resulted  iti  cystitis. —  Local  Condition.  When  tlie  bladder  was  opened  it 
was  found  •  lined  with  a  mass  of  granulations,  which  bled  readily. —  Trcntment. 
On  the  10th  day  after  opening  the  Ijladder,  cellulitis  and  local  peritonitis  came  on 
and  she  was  sick  for  3  months  ;  after  a  year,  finding  no  disease  with  the  endo- 
scope, the  fistula  was  closed,  8  sutures  being  used  ;  after  the  bladder  had  gradually 
become  dilated,  tln.'re  was  no  farther  difficulty. — Duration  of  Treatment,  24  months  ; 
Result,  cured. 


FOR    THE    RELIEF    OF    CYSTITIS.  709 

191  (lxxiv.).  Ailmittid  June  22,  1808.  Age  39.  Social  relation,  married.  Age 
at  inarriiige  21.  Sterile. 
History.  At  17  arrested  tlic  ineiistrual  How  by  putting  her  feet  in  cold  water; 
this  led  to  irritation  of  the  hhidder  ;  shortly  after  marriage  took  cold  ;  was  confined 
to  bed  for  several  months  afterwards,  and  had  never  after  been  free  from  irritation 
of  the  bladder  ;  had  an  aliscess  which  emptied  into  the  bladder  ;  fifteen  months 
previous  to  admission,  sudden  incontinence  of  urine  came  on. — Local  Cotidition. 
After  an  attack  of  cellulitis,  an  abscess  formed  and  refilled  a  number  of  times ; 
while  under  ether  tlie  remains  could  be  felt  on  the  left  side,  extending  between 
tlie  uterus  and  the  bladder  under  the  broad  ligament  towards  the  ovary  ;  the 
bladder  was  contracted  and  the  uterus  immovable ;  the  opening  into  the  bladder 
entered  the  vagina  just  in  front  of  the  uterus. —  Trfutinent.  As  it  was  found  that 
the  bladder  was  not  emptied  by  this  sinus,  the  condition  explained  the  fact  that 
she  had  not  been  entirely  relieved  after  the  urine  began  to  escajw  ;  it  was  thought 
best  to  enlarge  this  opening ;  death  from  uraemia  took  jjlace  5.5  hours  after  the 
operation. — Duration  of  Treatment,  55  hours  ;  Result,  died. — Remarks.  The  imme- 
diate cause  of  death  was  the  use  of  ether,  with  advanced  disease  of  the  kidney. 

192.  Admitted  Oct.  13,  1868.     Age   33.     Social   relation,  married.     No.  of  child- 
ren 1. 

History.  After  her  labor,  which  lasted  75  hours,  there  remained  incontinence 
of  urine  ;  this  difficulty  had  existed  two  years. — Local  Condition.  The  urethra 
was  found  patulous  enough  to  admit  the  end  of  the  index  finger,  as  if  it  had  been 
lacerated  by  dilatation  ;  there  had  been  laceration  of  the  perineum,  and  a  cysto- 
cele  existed. —  Treatment.  As  it  was  thought  the  loss  of  urine  might  be  due  to 
dragging  on  the  urethra,  the  operation  for  cystocele  was  done  and  then  the 
perineum  closed,  but  without  benefit ;  the  irritated  bladder  was  then  examined 
by  the  endoscope,  and  found  extensively  ulcerated  about  its  neck  ;  this  condi- 
tion, for  a  time,  received  local  treatment,  whicli  seemed  to  act  as  a  source  of  irri- 
tation ;  after  two  years'  treatment  by  various  means,  it  was  at  length  decided  to 
open  the  base  of  the  bladder  ;  at  the  end  of  two  weeks  it  had  healed,  and  she 
was  discharged,  greatly  relieved  :  to  wash  out  the  bladder  daily  and  return  at 
the  end  of  six  months. — Result,  improved. — Remarks.  This  woman  entirely 
neglected  herself  on  leaving  the  Hospital,  allowed  the  opening  to  close,  and  finally 
died  of  Bright's  disease. 

193.  Admitted  Oct.  5,  1869.     Age  19.     Social  relation,  single. 

History.  After  exposure  to  cold  a  year  previous  to  admission,  began  to  suffer 
from  irritation  of  the  bladder. — Local  Condition.  Cystitis  ;  vaginitis ;  general 
health  much  impaired. —  Treatment.  After  local  treatment  for  a  month  by  means 
of  the  endoscope  and  with  no  benefit,  the  bladder  was  opened,  with  entire 
relief. 

194.  Admitted  March  31,  1871.     Age  27.     Social  relation,  married.     No.  of  child- 
ren 1. 

History.  Two  years  previous  to  admission  had  a  large  vesico-vaginal  fistula 
closed  ;  a  few  weeks  after  her  discharge  she  began  to  suffer  from  irritation  of  the 
bladder  ;  she  became  pregnant  and  was  delivered  at  the  end  of  a  year  ;  the  diffi- 
culty with  the  bladder  increased,  and  she  returned  to  the  Hospital  two  years  after 
closure  of  the  fistula. — Local  Condition.  Cystitis,  with  the  bladder  much  con- 
tracted and  its  coats  thickened. —  Treatment.  As  the  vagina  was  much  shortened, 
from  the  great  loss  of  tissue  necessitating  the  bringing  together  of  the  cervix  and 
neck  of  the  bladder,  a  transverse  opening  had  to  be  made  along  the  old  line  of 
union ;  the  loss  of  blood  was  great ;  the  bladder  was  washed  out  several  times  a 
day  for  nine  months,  when  the  opening  was  closed  with  8  sutures. — Duration  of 
Treatment,  12  months  ;  Result,  cured. 

195.  Admitted  Oct.  2,  1871.     Age  35.     Social  relation,  married.     Age  at  marriage 
16.     Sterile. 

History.  Began  to  suffer  with  irritation  of  the  bladder  from  the  time  of  mar- 
riage, which  was  due  to  sexual  intercourse. — Local  Condition.  A  short  vagina 
was  the  beginning  of  her  trouble  after  marriage,  and  this  source  of  irritation  led 
to  cystitis. —  Treatment.  Shortly  after  admission  the  bladder  was  opened,  with 
great  relief  at  first  ;  two  weeks  after  had  an  attack  of  cellulitis,  from  which  she 
did  not  recover  for  two  months,  but  was  then  in  good  condition. 


710  CASES    OF    VESICO -VAGINAL    FISTULA. 

196.  Admitted  Feb.  9,  1872.     Age  22.     Social  relation,  single. 

History.  For  six  years  had  suffered  from  irritation  of  the  Madder,  from  no 
known  cause. — Local  Condition.  No  pus  found  in  the  urine ;  the  endoscope 
showed  the  existence  of  an  erosion  at  the  neck  of  the  bladder. —  Treatment.  An 
opening  made  in  the  hase  of  the  bladder,  which  closed  after  a  month ;  opened 
again,  but  at  the  end  of  six  months  had  not  materially  improved  ;  the  urethra 
was  then  laid  ojsen  from  a  quarter  of  an  inch  of  the  meatus  to  the  neck  of  the 
bladder,  without  cutting  through  at  this  point ;  the  diseased  surface  was  thus 
exposed,  and  healed  after  application  of  the  nitrate  of  silver  and  keeping  the 
parts  clean  ;  the  opening  in  tlie  urethra  was  afterwards  closed  at  one  operation. 
— Duration  of  Treatment,  IS  months  ;  Result,  cured. — Remarks.  Aftewards  married, 
had  a  child,  and  remained  in  good  health. 

197.  Admitted  Oct.  6,  1873.     Age  23.     Social  relation,  single. 

History.  Suffered  a  year  from  irritation  of  the  bladder  resulting  from  exposure 
to  cold. — Local  Condition.  After  opening  the  bladder,  a  fissure  was  found  in  one 
of  the  folds  at  the  neck  ;  no  disease  of  the  bladder. —  Treatment.  Through  the 
opening  in  the  base  of  the  bladder  the  fissure  was  brought  into  view  ;  this  was 
snipped  with  a  pair  of  scissors  ;  the  surface  rapidly  healed,  but  made  no  advance 
by  local  treatment ;  fistula  was  closed  with  10  sutures. — Duration  of  Treatment,  8 
•weeks  ;  Result,  cured. 

198.  Admitted'DeQ,.12,  l^Ti.     Age  45.     Social  relation,  single. 

History.  Obliged  to  empty  the  bladder  every  ten  minutes  diTring  the  past  year, 
or  the  urine  would  escape  and  continue  to  flow  until  the  bladder  had  been  evacu- 
ated fully. — Local  Condition.  The  urine  was  found  loaded  with  pus  ;  granulations 
could  be  felt  with  a  sound  at  the  fundus  and  other  portions  of  the  bladder. — 
Treatment.  After  washing  out  the  bladder  for  a  month,  without  any  benefit,  an 
opening  was  made  in  the  base  of  the  bladder  ;  through  the  opening  applications 
were  made  to  the  granulations,  and  the  bladder  was  washed  out  frequently. 

199.  Admitted  April  28,  1874.     Age  30.     Social  relation,  married. 

History.  From  childhood  had  suffered  from  irritatioji  of  the  bladder. — Local 
Condition.  Found  the  uterus  retroverted,  which  was  originally  the  cause  of  the 
cystitis  ;  the  urine  contained  pus,  but  no  casts. —  Treatment.  The  uterus  was 
replaced,  and  then  the  opening  was  made  into  the  bladder  ;  an  artery  was  divided 
at  the  upper  angle  which  required  a  stitch,  twisted  as  a  suture,  to  arrest  it ; 
improved  rapidly  after  the  operation. 

200.  Admitted  June  15,  1874.     Age  31.     Social  relation,  single. 

History.  Had  been  operated  on  for  the  relief  of  cystitis  twenty  months  previous 
to  admission. — Local  Condition.  A  fistula  was  found,  an  inch  and  a  half  long, 
in  the  bladder,  Avhile  the  urethra  had  been  laid  open  for  two-thirds  of  its  length. 
—  Treatment.  The  edges  were  denuded,  as  in  an  ordinary  fistula,  and  brought 
together  by  12  sutures  ;  the  opening  in  the  iirethra  was  closed  at  the  same  time. 
— Duration  of  Treatment,  3  weeks ;  Result,  cured. 

201.  .4rfOTi«e(?  March  21,  1875.     Age  32.     Social  relation,  married.     Age  at  marri- 
age 24.     Sterile. 

History.  The  bladder  had  been  opened  three  years  before  for  the  relief  of  cys- 
titis ;  three  attempts  had  been  made  to  close  it  without  success. — Local  Condition. 
Two  small  openings  remained,  the  original  one  having  been  united  in  the  central 
portion. —  Treatment.  The  septum  between  the  openings  was  divided,  the  edges 
freshened,  and  brought  togetlier  with  7  sutures. — Duration  of  Treatment,  3  weeks  ; 
Result,  cured. — Remarks.  Had  been  operated  on  three  times  in  the  attempt  to 
close  the  fistula. 

202.  Admitted  Dec.  12,  1875.     Age  17.     Social  relation,  sin^fle. 

History.  Two  years  before,  the  bladder  had  been  opened  for  tlie  relief  of  cys- 
titis.— Local  Condition.  Fistula  in  the  median  line  large  enough  to  admit  the 
index  finger.  —  Treatment.  Closed  by  one  operation,  using  6  sutures. — Duration  of 
Treatment,  6  weeks  ;  Result,  cured. 


DISEASES    OF    THE    URETHRA.  711 


CHAPTER    XXXIV. 

DISEASES  OF  THE  URETHRA. 

I  ENTER  upon  a  consideration  of  these  diseases  with  mistrust,  for  our 
knowledge  of  them  is  yet  very  limited,  on  account  of  the  great  diffi- 
culty met  with  in  making  proper  inspections.  What  knowledge  we 
do  possess  is  based  on  pathological  views  as  little  trustworthy  as  those 
which  were  held  in  reference  to  uterine  diseases  a  generation  ago.  It 
is  to  be  hoped  that  the  time  is  not  far  distant  when  the  ingenuity  of 
some  one  will  furnish  us  with  effective  means  of  inspecting  the  urethra, 
and  thus  throw  as  much  light  upon  the  nature  and  treatment  of  its 
diseases,  as  was  done  for  the  uterus  when  Sims's  speculum  was  intro- 
duced. This  is  the  more  to  be  desired  because  it  is  as  rare  to  find 
the  mucous  membrane  of  the  urethra  in  a  perfectly  healthy  condition, 
as  it  is  that  of  the  throat.  At  least  this  is  true  of  those  women  who 
have  passed  under  my  observation,  suffering  from  some  form  of  uterine 
disease.  The  cause  of  this  is  yet  to  be  determined.  It  may  be  but  an 
indication  of  a  general  diseased  condition  of  the  mucous  membranes 
throughout  the  body,  the  result  of  impaired  nutrition  ;  or  it  may  be 
that  the  condition  of  the  urethral  mucous  membrane  is  only  an  effect 
of  the  obstructed  circulation  in  the  pelvis,  a  result  also  of  impaired 
nutrition  similar  to  what  obtains  in  the  uterus. 

For  examining  the  urethra,  Dr.  A.  Reeves  Jackson,  of  Chicago, 
111.,  recommends  a  tapering  glass  tube,^  closed  at  one  end,  and 
provided  with  a  flange  at  the  other.  It  has  a  fenestra  on  one  side, 
and  resembles  in  shape  the  well-known  rectal  speculum,  though 
much  smaller.  This  instrument  is  two  and  a  half  inches  lono;,  and 
half  an  inch  in  outside  diameter,  but  several  sizes  would  be  found 
useful.  It  is  claimed  that  a  very  thorough  inspection  of  the  urethra 
may  be  made  with  this  speculum.  It  greatly  facilitates  making  ap- 
plications at  special  points,  and  is  useful  for  the  removal  of  certain 
growths  ;  but  the  field  of  inspection  it  offers  is  very  limited. 

Dr.  Skene,  of  Brooklyn,  has  employed  a  somewhat  similarly  shaped 
instrument,  which  he  has  perfected  as  a  urethral  endoscope,  describing 
it  as  follows  •}  "  The  instrument  consists,  1st,  of  a  glass  tube,  precisely 

'  Gyncecological  Transactions,  vol.  ii.  1877. 

2  Am.  Journ,  of  Obstetrics,  etc.,  Oct.  1878,  p.  768. 


712 


DISEASES    OF    THE    URETHRA. 


like  an  ordinary  test  tube,  varying  in  size  according  to  tlie  purpose  for 
which  it  is  used,  and,  2d,  of  a  section  of  a  cylinder  made  black,  and 
having  a  mirror  set  at  a  rather  acute  angle  at  its  distal  extremity. 
The  glass  tube  is  first  introduced  into  the  cylindrical  section  with  the 


¥m.  116. 


Skene's  Endoscope. 

mirror,  and  then  with  an  ordinary  concave  forehead  mirror,  light  is 
thrown  in  upon  the  mirror  within  the  tube.  The  cylindrical  section 
can  then  be  moved  forwards  or  backwards,  or  turned  around,  and  thus 
the  operator  is  able  to  explore  the  canals  or  cavities  into  which  it  is 
introduced.  The  advantages  claimed  for  the  instrument  are,  that 
being  a  closed  tube,  it  can  be  introduced  into  the  bladder  without 
escape  of  urine ;  and  the  operator  is  not  annoyed  by  the  condensation 
of  vapor  on  the  mirror ;  for  the  tube  protects  the  mirror,  and  the 
entire  urethra  can  be  explored  with  the  greatest  facility."  This  instru- 
ment is  unquestionably  a  useful  one,  and  a  valuable  addition,  so  I 
should  judge  from  my  limited  use  of  it.  The  eye  of  the  operator  has 
to  be  educated,  as  in  the  use  of  the  male  endoscope,  to  the  appearance 
of  the  tissues.  For  we  find  that  the  lining  membrane  of  the  urethra 
becomes  blanched  on  the  introduction  of  the  cylindrical  instrument, 
from  its  temporarily  obstructing  the  circulation. 

I  have  been  in  the  habit  of  using  a  diminutive  instrument,  resem- 
bling a  Sims's  speculum,  but  made  more  pointed,  the  patient  being 
placed  for  examination  on  the  left  side.  By  drawing  the  urethra 
away  from  under  the  arch  of  the  pubes,  in  the  same  direction  in  which 
the  perineum  is  retracted,  a  fair  exposure  can  be  made  of  the  lining 
membrane  near  the  outlet.  I  have  also  used  the  curette  forceps  for 
the  same  purpose.  Both  of  these  instruments  give  great  facility  for 
making  local  applications,  but,  like  all  others  yet  devised,  they  enable 
us  to  see  but  little  of  the  parts  at  ihe  neck  of  the  bladder.     The 


CLASSIFICATION  —  URETHRITIS.  713 

endoscope  offers  the  best  means  for  exploration  in  this  neighborhood, 
and  yet,  on  account  of  its  limited  range,  it  is  far  from  satisfactory. 

In  fact  with  our  means  for  exploration  at  the  present  time,  I  can- 
not suggest  a  better  procedure  than  to  open  the  urethra  over  the  point 
we  Avish  to  bring  into  view.  Of  course  this  must  not  be  done  care- 
lessly or  by  an  incompetent  person.  The  opening  should  always  be 
made  in  the  median  line,  but  never  extended  through  the  meatus  or 
through  the  neck  of  the  bladder.  It  will  always  prove  comparatively 
an  easy  matter  to  close  such  an  opening. 

In  a  general  manner  the  disease  of  the  urethra  may  be  classified 
under  the  following  heads:  — 

1.  Inflammation  of  the  mucous  membrane,  or  urethritis. 

2.  Pedunculated,  vascular,  and  neuromatoid  growths. 

3.  Prolapse  of  the  mucous  and  submucous  tissues. 

4.  Fissures  at  the  neck  of  the  bladder. 

5.  Urethrocele. 

6.  Laceration  of  the  urethra  from  dilatation. 

G-eiieral  inflammation  of  the  mucous  membrane,  or  urethritis,  may 
be  caused  by  an  extension  of  gonorrhoea!  inflammation  from  the  vagina 
into  the  urethra,  from  exposure  to  cold,  or  it  may  result  from  direct 
violence.  Whenever  the  lining  membrane  of  the  urethra  becomes 
inflamed  from  any  cause,  the  process  must  be  arrested  as  soon  as 
possible,  or  the  inflammation  may  extend  to  the  bladder  and  lead  to 
more  serious  difficulties.  The  patient  must  be  kept  in  the  recumbent 
position,  the  bowels  acted  on  by  saline  purgatives,  and  the  urine  made 
bland  by  diluent  drinks.  Hot-water  vaginal  injections  and  warm  sitz- 
baths  are  essential.  When  it  is  possible  to  do  so,  the  urethral  tract 
should  be  Avashed  out  several  times  a  day  with  warm  water.  By 
placing  the  patient  on  a  bed-pan,  a  large  portion  of  the  urethra  can 
be  washed  out  by  simply  throwing  the  water  against  the  outlet,  much 
of  which  will  enter  and  again  escape.  If  the  inflammation  is  not 
too  great,  a  pair  of  long  dressing  forceps  can  be  introduced,  and  by 
separating  the  blades  the  canal  will  be  opened  quite  widely.  It  is 
not  advisable  that  the  injection  should  pass  into  the  bladder,  since  it 
would  be  the  means  of  spreading  the  disease.  But  if  it  be  evident  that 
the  bladder  has  become  involved,  it  wdll  be  necessary  to  wash  out  its 
cavity  also.  A  cone-shaped  urethral  speculum  should  be  used,  made 
of  six  wire  bars  placed  at  equal  distances,  and  opening  out  gradually, 
so  that  the  neck  of  the  bladder  can  be  sufficiently  dilated.  Through 
this  the  warm  water  may  be  injected,  or  a  small  rubber  tube  can  be 


T14  DISEASES    OF    THE    URETHRA. 

attached  to  the  small  nozzle  of  a  Davidson's  syringe  and  passed  into 
the  bladder,  enough  room  being  thus  left  for  the  escape  of  the  water 
into  the  bed-pan.  The  speculum  should  be  very  carefully  introduced, 
the  canal  should  only  be  dilated  sufficiently  for  the  purpose,  and  the 
danger  of  causing  laceration  at  the  neck  of  bladder  should  always  be 
borne  in  mind.  After  washing  out  the  urethra,  the  extract  of  pinus 
Canadensis,  to  which  a  little  impure  carbolic  acid  has  been  added, 
should  be  thoroughly  applied.  Sometimes  an  application  of  a  weak 
solution  of  nitrate  of  silver  or  of  impure  carbolic  acid  alone  Avill  be 
found  useful.  Then,  as  the  case  improves,  vaseline  or  a  little  tannin 
and  glycerine  will  protect  the  parts  sufficiently. 

Pedunculated.,  vascular,  and  neuromatoid  growtlis  from  the  mucous 
membrane  constitute  the  most  frequent  lesions  found  in  the  urethra. 
The  pedunculated  follicular  growths  are  found  in  any  portion  of  the 
canal,  while  the  other  varieties  are  more  frequently  situated  within 
the  meatus,  and  the  small  vascular  growths  are  the  most  common. 

These  growths  in  the  urethra  frequently  excite  a  great  deal  of  reflex 
irritation,  which  may  be  centred  in  the  bladder,  uterus,  rectum,  or 
elsewhere,  while  the  true  cause  may  be  long  unsuspected,  and  some- 
times never  detected.  I  have  seen  cases  of  vaginismus  and  other 
neuroses  which  seemed  to  be  due  to  some  uterine  disorder,  when  the 
primary  cause  of  irritation  was  located  in  the  urethra.  In  this  re- 
spect there  is  a  close  resemblance  between  the  symptoms  caused  by 
some  urethral  growths,  and  those  which  sometimes  result  from  a  fissure 
in  ano,  and  in  every  instance  the  true  cause  of  the  trouble  may  be 
masked  by  the  more  obvious  uterine  difficulty. 

I  am  not  certain  regarding  the  true  pathology  of  these  lesions  which 
I  have  described  as  neuromatoid  growths.  These  are  small  vascular 
bodies  of  a  deep  red  color,  Avhich  become  exquisitely  sensitive,  and 
produce  much  reflex  irritation.  Therefore,  without  direct  proof  to 
the  contrary,  I  cannot  but  assume,  from  the  symptoms  presenting, 
that  fibres  of  the  sympathetic,  accompanying  the  small  vessels  in  these 
growths,  become  involved,  and  undergo  some  change.  But  what  the 
change  is  in  either  nerve  fibres  or  in  the  bloodvessels  which  produce 
these  vascular  tumors  I  am  unable  to  surmise. 

For  all  these  growths  the  treatment  is  identically  the  same.  They 
should  be  drawn  up  free  from  the  deeper  tissues,  removed  with  a 
pair  of  scissors  having  rather  dull  edges,  and  after  removal  the  site 
should  be  touched  with  the  cautery  or  nitric  acid.  The  point  of  a 
blunt  hook  heated  in  a  spirit  lamp  answers  the  purpose.  Or  nitric 
acid  may  be   applied  from  the  end  of  a  Avooden  match,  care  being 


PROLAPSE    OF    THE    MUCOUS    AND    SUE-MUCOUS    TISSUES.      715 

taken  to  neutralize  the  action  of  the  acid  immediately  afterwards  by 
the  application  of  a  portion  of  cotton  soaked  in  a  solution  of  carbonate 
of  soda.  Whenever  these  growths  are  extensive  enough  to  involve 
materially  the  calibre  of  the  meatus,  it  is  better  to  limit  the  operation, 
and  watch  the  eft'ects.  It  is  an  error,  and  one  too  often  committed, 
to  remove  at  a  single  operation  so  much  as  to  narrow  seriously  the 
outlet,  for  this  always  leads  to  irritation  of  the  bladder,  and  to  cys- 
titis, Avhenever  the  stream  of  urine  is  habitually  obstructed  in  its 
escape. 

Prolapse  of  the  Mucous  and  Submucous  Tissues. — This  prolapse 
presents  itself  at  the  outlet  of  the  urethra,  projecting  from  the  upper 
or  lower  portion  of  the  passage,  or  occupying  the  entire  circumference 
of  the  canal.  The  escape  of  urine  from  the  bladder  becomes  neces- 
sarily impeded,  and  as  the  obstruction  increases  more  or  less  tenesmus 
is  constantly  excited,  which  in  time  adds  to  the  difficulty.  Ulti- 
mately, the  whole  urethral  canal  becomes  displaced,  and  pressed  for- 
ward, or  rolled  out,  by  a  prolapse  of  the  superabundant  tissue  about 
the  neck  of  the  bladder. 

The  urethral  canal  dilates,  necessarily,  in  proportion  to  the  extent 
of  prolapse,  and  as  the  circulation  is  obstructed  the  tissues  become 
oedematous.  When  such  a  condition  remains  long  without  relief,  cys- 
titis must  be  the  inevitable  consequence,  the  opium  habit  follows,  and 
death  from  disease  of  the  kidneys  will  be  the  termination. 

When  the  prolapse  is  confined  to  the  upper  side,  and  consists  more 
particularly  of  the  tissues  situated  at  the  outlet  of  the  urethra,  it  may 
be  treated  as  hemorrhoids  are,  i.  e.,  tied  and  cut  off.  To  do  this  we 
are  to  catch  up  the  tissues  on  a  tenaculum,  cut  around  the  base, 
through  the  mucous  tissue,  ligate  in  two  sections  by  a  double  thread, 
and  cut  off  the  tissue  close  to  the  ligature.  Care,  however,  must  be 
exercised  to  limit  the  traction  to  simply  lifting  the  tissues.  I  have 
twice  had  a  thrombus  to  occur  as  a  consequence  of  inattention  to  this 
precaution  on  the  part  of  my  assistant,  and  in  one  instance  the  acci- 
dent proved  to  be  of  a  serious  character.  I  operated  on  a  case  in  the 
Woman's  Hospital,  several  years  ago,  in  which  a  thrombus  formed 
from  the  rupture  of  some  small  bloodvessel  in  the  cellular  tissue. 
This  dissected  off  the  bladder  from  the  pubes,  and  extended  above  the 
symphysis,  and  downward  through  the  urethral  outlet,  dilating  it  to 
an  enormous  size.  To  prevent  extensive  sloughing,  and  to  give  relief, 
it  was  necessary  to  open  the  thrombus,  and  turn  out  the  clot.  This 
was  done  as  far  as  it  could  be  accomplished,  and  a  large  cavity  was 
left,  which  soon  became  a  pus-secreting  surface.     This  gradually  filled 


716  DISEASES    OF    THE    URETHRA. 

up  by  granulation,  and  the  result  was  a  radical  cure  of  the  prolapse, 
but  only  after  much  suffering. 

When  the  lining  membrane  presents  at  the  outlet,  as  a  circular 
prolapse,  it  is  not  good  practice  to  remove  it  in  a  mass,  as  is  some- 
times done.  Only  a  temporary  benefit  would  result  from  its  removal, 
and  the  ultimate  consequences  would  be  a  most  serious  and  permanent 
constriction  of  the  outlet  of  the  canal. 

Such  a  case  should  be  treated  as  for  cystitis,  by  making  a  vesico- 
vaginal fistula,  with  the  view  to  the  passage  of  the  urine  in  another 
direction,  thus  obtaining  rest  for  the  hypertrophied  tissues.  After 
making  the  fistula,  the  prolapsed  tissues  are  to  be  carefully  returned, 
and  pushed  back  into  the  bladder  by  a  steel  sound  large  enough  to 
fill  the  canal.  The  instrument  must  not,  of  course,  be  withdra^vn  by 
pulling  it  directly  out,  since  this  would  at  once  reproduce  the  original 
condition.  It,  however,  can  be  removed  Avithout  causing  the  prolapse, 
by  rotating  it  while  the  fingers  make  firm  pressure  upward  and  back- 
ward along  the  course  of  the  urethra.  The  tissues  are  to  be  returned 
from  time  to  time  in  this  manner,  and  made  to  contract  by  the  appli- 
cation of  the  strong  tincture  of  iodine.  A  conical  ear  speculum 
afibrds  the  best  means  for  making  the  application  to  the  urethra,  and 
should  be  introduced  as  close  up  to  the  neck  of  the  bladder  as  possible. 
When  withdrawn  it  should  be  rotated,  so  as  to  allow  the  excess  of 
iodine  to  follow  up  towards  the  outlet,  thus  rendering  the  application 
the  more  complete.  After  the  tissues  are  returned  the  circulation  be- 
comes restored,  and  the  urethra  gradually  contracts  to  its  normal  size. 
After  the  urethra  has  been  restored  to  its  normal  condition,  the 
fistula  which  had  been  made  for  its  relief  may  be  closed.  But  before 
this  is  done  the  original  cause  of  the  tenesmus  should  be  sought  out, 
and  if  due  to  hemorrhoids  or  fissure  in  the  rectum,  or  to  inflammation 
in  the  bladder,  or  to  fissure  at  its  neck,  or  to  any  other  cause,  this 
must  be  first  relieved  to  guard  against  a  recurrence  of  the  difficulty. 

I  am  satisfied  that  many  of  these  cases  may  be  permanently  cured 
by  making  a  button-hole  slit  in  the  urethra,  through  which  the  loose 
tissues  may  be  drawn  back  from  the  meatus,  secured  in  the  edges, 
the  excess  cut  off,  and  the  opening  closed.  This  operation  would 
resemble  the  drawing  of  a  portion  of  a  handkerchief  through  a  button- 
hole in  a  coat,  all  being  drawn  through  except  the  portion  grasped 
by  the  hand  on  the  other  side.  Applying  this  principle  to  the 
urethra,  it  will  be  seen  that  after  the  slit  has  been  properly  made, 
traction  on  the  tissues  should  be  directed  from  before  backwards. 
AVhile  an  assistant  is  holding  up  excess  of  tissue  a  large-sized  sound 


FISSURES    AT    THE    NECK    OF    THE    BLADDER.  717 

should  be  introduced  so  as  to  smooth  out,  as  it  were,  the  lining  mem- 
brane and  carry  it  towards  the  neck  of  the  bladder,  and  place  the 
canal  somewhat  on  the  stretch,  "While  this  instrument  is  in  place, 
the  sutures  should  be  introduced  entirely  through  the  flaps  into  the 
urethra  so  as  to  transfix  the  lining  membrane  along  the  edges  of  the 
■wound ;  the  excess  of  tissue  is  then  removed  with  a  pair  of  scissors, 
and  the  opening  closed.  If  this  incision  be  made  just  in  front  of  the 
neck  of  the  bladder,  it  need  not  be  extended  towards  the  outlet  of  the 
urethra  to  a  greater  extent  than  will  just  allow  the  desired  amount 
of  tissue  to  be  drawn  through.  The  lining  membrane  must  become 
permanently  adherent  along  this  line,  after  which  the  lax  tissues  will 
be  confined  within  the  bladder,  and  no  prolapse  could  take  place  from 
beyond. 

AYhen  the  passage  has  been  permanently  dilated,  or  overstretched, 
it  may  be  restored  to  its  normal  size  by  placing  the  suture  further 
back,  at  the  proper  distance,  and  then  denuding  the  edges,  including  a 
sufficient  portion  of  the  inner  surface  of  the  canal.  By  this  means 
we  may  reduce  the  size  of  the  whole  canal,  or  any  portion  of  it. 

Fissures  at  the  Neck  of  the  Bladder. — We  are  so  seldom  able  to 
determine  by  ocular  proof  the  presence  of  fissures  at  the  neck  of  the 
bladder,  that  they  often  escape  notice,  and  may  even  be  unsuspected. 
There  are  no  characteristic  symptoms,  nor  any  which  may  not  be  due 
to  the  early  stages  of  cystitis  with  which  this  lesion  is  so  closely  as- 
sociated in  its  causal  and  semiological  relations.  The  use  of  the 
microscope  might  determine  the  fact  that  the  kidneys  as  well  as  the 
bladder  Avere  in  a  healthy  condition.  By  exclusion  only  may  we 
suspect  the  existence  of  a  fissure  at  the  neck  of  the  bladder,  for  all 
the  symptoms  might  be  purely  reflex,  and  due  to  disease  situated 
elsewhere.  I  have  never  been  able  to  detect  a  fissure  by  means  of 
the  endoscope,  although  Dr.  Skene  has  been  more  successful. 

My  experience  holds  out  to  me  only  one  reliable  remedy  for  the 
class  of  symptoms  under  consideration,  be  the  cause  Avhat  it  may. 
This  is  rest  to  muscular  tissue,  which  is  to  be  secured  only  by  open- 
ing the  bladder  and  treating  the  case  as  for  cystitis,  which  condition, 
if  it  does  not  coexist,  must  inevitably  be  produced.  The  vesico- 
vaginal septum  is  to  be  opened  in  the  manner  already  described,  and 
as  close  up  to  the  neck  of  the  bladder  as  can  be  done  without  involv- 
ing it.  While  the  speculum  is  still  in  position,  the  edges  of  the  in- 
cision are  to  be  widely  opened  by  means  of  a  double  tenaculum  w^hich 
is  to  be  held  afterwards  by  an  assistant.  It  becomes  then  possible  to 
detect  these  fissures  by  opening  the  folds  around  the  neck  on  the 


718  DISEASES    OF    THE    URETHRA. 

bladder  surface.  This  can  be  done  by  the  aid  of  the  tenaculum,  and 
the  examination  is  greatly  facilitated  by  the  use  of  a  laryngeal 
mirror  attached  to  a  copper  handle  that  can  be  bent  at  any  needed 
angle.  Although  a  few  weeks  rest  and  the  uce  of  hot  water  injections 
are  generally  sufficient  to  cause  a  fissure  to  heal,  it  is  always  good 
practice  to  expedite  the  healing  process  by  drawing  the  edge  of  a 
scalpel  through  the  angle  of  the  ulcerating  line.  This  may  cause 
some  bleeding  temporarily,  but  is  no  disadvantage,  as  it  may  be 
arrested,  if  too  free,  by  an  injection  of  hot  water. 

Urethrocele. — But  little  need  be  said  as  to  the  treatment  of  this 
condition ;  it  has  been  already  referred  to  under  other  heads.  If 
disease  of  the  bladder  still  exists,  or  any  external  cause,  it  must  be 
remedied.  When  Ave  have  to  treat  simply  the  result  of  some  previous 
exciting  cause,  and  recognize  this  as  consisting  of  more  or  less  dilata- 
tion of  the  urethral  canal,  or  of  hypertrophied  tissue  external  to  the 
urethral  wall,  the  treatment  becomes  simplified.  The  canal  is  to  be 
lessened  in  diameter  by  the  method  already  given,  and  at  the  same 
operation,  even  extensive  hypertrophy  of  the  neighboring  tissues 
may  be  removed  with  a  pair  of  scissors,  and  the  whole  closed  in  one 
line  of  union.  Or,  if  deemed  more  advantageous,  the  excess  of  tissue 
may  be  drawn  backward  and  disposed  of  as  when  complicated  with 
procidentia. 

After  every  operation  of  the  kind  it  Avill  always  be  well  to  close 
the  perineum,  if  ruptured,  that  the  parts  may  be  properly  supported, 
so  as  to  guard  against  a  return  of  the  urethrocele. 

Lacerations  of  the  Urethra  from  Dilatation. — It  is  claimed  that 
dilatation  of  the  urethra  offers  superior  advantages  for  the  purpose  of 
forming  a  diagnosis  of  growths  on  the  uterine  wall,  and  as  to  the  con- 
dition of  the  bladder  itself.  A  difterence  of  opinion  exists  as  to  the 
advantages  gained,  but  if  the  method  should  be  proved  fully  equal  in  its 
diagnostic  value  to  the  claims  advanced,  still  the  consequences  which 
sometimes  follow  dilatation  are  serious  enough  to  give  rise  to  a  doubt 
as  to  its  propriety.  It  cannot  be  questioned  that,  with  all  due  care, 
laceration  will  sometimes  occur,  and  that  a  certain  number  of  cases 
are  left  with  permanent  incontinence  after  the  operation. 

At  a  meeting  of  the' New  York  Obstetrical  Society,  held  March  5, 
1878,  the  history  of  a  case  of  laceration,  as  given  at  the  end  of  this 
article,  was  presented  and  discussed.  I  maintained  that  the  same  in- 
formation could  be  gotten  by  examination  from  the  vagina,  or  by 
means  of  conjoined  manipulation.  But  granting  all  that  is  claimed 
for  dilatation,  my  experience  of  two  cases  of  incontinence  out  of  a 


DANGER    OF    DILATING    THE    URETHRA.  719 

total  of  eleven  thus  operated  on  for  diagnostic  purposes,  demonstrates 
the  unjustifiable  nature  of  the  procedure.  One  of  these  cases  I  after- 
wards cured  on  closing  an  opening  that  I  had  made  to  ascertain  the 
condition  of  the  urethra  which  had  been  dilated,  and  the  history  will 
be  found  already  detailed  in  an  earlier  part  of  this  work.  The  other 
remained  for  weeks  after  the  accident  in  the  same  condition,  and  was 
(dismissed  as  incurable.  Dr.  Noeggerath,  who  has  certainly  had  more 
experience  in  this  operation  than  any  one  else,  had  been  so  fortu- 
nate as  to  produce  permanent  incontinence  in  but  two  out  of  seventy- 
five  cases,  as  he  stated  during  the  discussion.  I  am  satisfied  that 
with  any  other  operator,  less  expert,  the  proportion  would  have  been 
greater.  But  accepting  this  2.66  per  cent,  as  indicative  of  the  risk 
which  is  involved  in  this  operation,  I  must  still  hold  that  the  alleged 
advantages  in  no  degree  compensate  for  it,  particularly  since  an 
artificial  opening  in  the  base  of  the  bladder  gives  equal  facilities  for 
exploration,  and  is  attended  with  no  such  risk  of  incontinence. 

The  rule  is  almost  Avithout  exception,  that  in  the  event  of  much  in- 
jury from  the  overstretching,  incontinence  of  urine  follows.  The  only 
exception  to  the  rule  within  my  knowledge,  was  in  the  case  of  a 
young  woman  who  came  under  the  observation  of  Dr.  Paul  F.  Mund^, 
and  who  had  so  much  cicatrization  following  the  dilatation,  that  her 
bladder  could  only  be  relieved  by  the  regular  use  of  the  catheter. 
The  doctor  placed  this  case  under  my  care,  and  as  a  choice  of  the 
lesser  evil,  and  to  avoid  cystitis  in  the  future,  I  made  a  permanent 
opening  in  the  base  of  the  bladder. 

Incontinence  of  urine  never  occurs  directly  from  laceration  of  the 
urethra  proper,  nor  is  it  a  consequence  always  of  the  injury  at  the 
neck  of  the  bladder,  since  I  believe  that  more  or  less  tearing  of  the 
tissues  must  occur  in  every  instance  in  which  the  canal  is  fully 
dilated.  The  urine  continues  to  be  lost  only  when  the  direction  of 
the  cicatricial  line  interferes  with  the  proper  closure  of  the  folds  at 
the  neck  of  the  bladder,  to  which,  as  has  already  been  stated,  the 
retentive  power  is  wholly  due.  The  whole  urethral  tract,  as  far  as 
the  neck  of  the  bladder,  may  be  lacerated  without  necessarily  inter- 
fering with  the  retentive  power ;  but  if  partially  lacerated,  so  far  as 
to  increase  the  diameter  and  leave  the  canal  patulous,  a  condition  is 
induced  which  will,  in  all  probability,  lead  to  inflammatory  changes 
in  the  bladder  by  which  the  tissues  of  the  urethra  will  be  drawn  so 
far  back  as  to  prevent  the  proper  falling  together  of  the  folds,  and 
the  retentive  power  will  be  lost.  When  treating  of  certain  forms  of 
vesico-vaginal  fistula  I  described  a  like  condition.    In  these  cases  the 


720  DISEASES    OF    THE    URETHRA. 

torn  urethral  tissue  pass  through  the  septum  at  a  right  angle  to  the 
natural  direction  of  the  canal ;  this  then  becomes  funnel-shaped,  Avith 
its  opening  presenting  towards  and  into  the  bladder.  I  have  seen 
other  instances  of  laceration,  when  the  canal  was  left  dilated  in  the 
anterior  portion,  and  with  some  contraction  about  the  meatus,  but  as 
the  neck  of  the  bladder  was  not  injured  there  was  no  incontinence. 
This  condition  must  always  lead  to  cystitis,  as  a  constatit  irritation 
is  kept  up  by  a  small  quantity  of  stale  urine  being  retained  within  the 
dilated  portion. 

I  have  had,  comparatively,  little  experience  in  repairing  these 
injuries.  In  one  instance  I  removed  successfully  such  a  pouch  by 
opening  the  urethra  and  restoring  the  canal  to  its  normal  size.  In 
another  instance,  when  the  neck  of  the  bladder  had  been  permanently 
drawn  back,  as  I  have  described,  I  lengthened  the  urethra  with  success. 
The  third  case  I  give  somewhat  in  detail,  as  it  fittingly  closes  this 
subject  with  a  description  of  the  pathological  changes  found  in  the 
advanced  stages  of  all  the  conditions  which  have  been  treated  of  as 
complicated  with  cystitis  : — 

Case  XLIX. — Jane  Morton,  aged  40,  unmarried,  was  admitted  to 
the  Woman's  Hospital,  Sept.  27,  1877. 

Menstruation  had  been  normal  since  its  first  appeai'ance.  Without 
any  known  cause,  cystitis  gradually  came  on  about  six  years  previous 
to  her  admission.  For  her  relief  an  artificial  vesico- vaginal  fistula 
•was  made  about  two  years  afterwards  in  Brooklyn.  This  gave  her 
entire  relief,  but  the  opening  was  closed  too  soon,  and  the  cystitis 
returned.  The  urethra  was  dilated  at  the  same  time,  since  which  she 
has  been  unable  to  retain  the  urine,  and  her  suffering  is  greatly 
increased. 

A  physical  examination  disclosed  laceration  of  the  urethra,  and  an 
irritable  and  contracted  bladder.  The  uterus  and  vagina  were  in  a 
normal  condition.  Examination  of  the  urine  gave  evidence  of  an  irri- 
table bladder,  but  none  of  any  kidney  difficulty. 

At  first  attempts  were  made  to  aid  the  retention  of  urine  by  main- 
taining pressure  against  the  symphysis  with  a  soft  India-rubber  pes- 
sary, but  without  success. 

Nov.  6.  Made  an  artificial  vesico-vaginal  fistula,  and  closed  the 
laceration  through  the  urethral  outlet.  From  thickening  and  contrac- 
tion of  the  bladder  the  urethra  was  drawn  backward,  and  presented 
the  appearance  as  if  a  gimlet-hole  had  been  made  through  the  septum 
just  behind  the  pubcs.  The  laceration  was  not  only  closed,  but  the 
canal  was  lengthened  in  a  forward  direction  fully  half  an  inch. 

13^/i.  The  sutures  were  removed,  and  the  union  found  perfect. 

Dee.  4.  Closed  the  fistula  with  fine  sutures.  This  was  done  as  no 
evidence  of  positive  disease  of  the  kidneys  had  been  detected,  nor  of 
the  bladder,  except  a  little  at  the  contracted  portion,  which  might  have 


PATHOLOGICAL    CHANGES    IN    CYSTITIS.  721 

resulted  from  the  constant  escape  of  urine.  I  was  disappointed,  how- 
ever, to  find,  after  closing  the  fistula,  that  the  urine  escaped  from  the 
urethra  as  hefore. 

1th.  Violent  paroxysms  of  vomiting  came  on  on  the  second  day 
after  the  operation,  and  the  urine  became  scanty  in  quantity.  Exami- 
nation of  the  urine  now  showed  a  large  amount  of  pus,  an  alkaline 
reaction,  and  a  specific  gravity  of  1.00('>.  Granular  casts  from  the 
tubes  were  found,  and  columnar  epithelium  from  the  pelvis  of  the 
kidney. 

^tli.  Patient  was  unable  to  retain  anything  on  the  stomach.  The 
vomiting  or  retching  continued,  except  when  controlled  by  morphine, 
and  was  of  that  explosive  character  peculiar  to  uroemic  poisoning. 
Thus  far  there  had  been  no  cerebral  symptoms,  and  vision  continued 
perfect,  and  there  was  no  headache.  There  had  been  no  movement 
from  the  bowels  since  previous  to  the  operation,  although  injections 
had  been  several  times  administered.  During  the  day  the  temperature 
ranged  from  99°-101°,  and  the  pulse  from  90-110.  Towards  night 
the  tongue  became  dry,  and  the  general  appearance  that  of  typhoid. 
At  9  A.M.  administered  by  enema  four  drops  of  croton  oil  in  a  little 
glycerine,  and  by  the  rectum  two  ounces  each  of  beef-tea  and  brandy 
every  three  hours,  and  this  was  continued  throughout  the  next  day, 
during  which  the  temperature  and  pulse  remained  unchanged,  and 
the  vomiting  continued.  During  the  evening  symptoms  of  cerebral 
disturbance  were  noted,  and  she  began  to  sink.  Between  1  and  2 
o'clock  P.  ]\r.  she  had  several  copious  movements  of  the  bowels,  due, 
it  was  thought,  to  the  action  of  the  croton  oil.  At  4  P.  M.  it  was  dis- 
covered that  there  existed  a  complete  suppression  of  urine  ;  she  was 
gotten  into  a  hot  bath  without  delay,  and  by  6.30  the  skin  began  to 
act  freely.  At  9  A.  M.  the  pulse  reached  130,  became  feeble  and 
intermitting.  Gave  brandy  and  wine  of  digitalis  hypodermically, 
and  this  was  repeated  as  needed  to  steady  the  action  of  the  heart. 
By  11  o'clock  P.  ^I.  the  pulse  had  been  reduced  to  115  per  minute, 
and  was  held  at  this  rate,  by  the  use  of  the  digitalis,  until  5  A.M., 
Dec.  10,  when  it  could  be  no  longer  influenced.  Coma  began  at  8 
A.M.,  the  vomiting  had  ceased,  and  there  had  been  no  convulsions  ; 
the  skin  w^as  dry,  the  pulse  feeble  and  intermitting.  She  Avas  placed 
in  a  vapor-bath  several  times  during  the  day,  but  without  affecting  the 
condition  of  the  kidneys,  and.  the  temperature  of  the  body  remained 
about  101°,  with  but  little  variation.  The  coma  became  complete  at 
4  o'clock  P.M.,  and  she  died  within  an  hour  afterwards. 

The  autopsy  was  made  by  Dr.  Maxwell,  who  furnished  the  follow- 
ing statement  of  the  condition:  Jane  Morton,  examination,  Dec.  11, 
1877.  Body  medium  stature,  fair  nourished,  rigor  marked,  no  ana- 
sarca.    Examination  of  urinary  organs  only. 

Pyo-nephrosis,  encapsulated  right  kidney,  occlusion  and  atrophy 
of  right  ureter ;  dilatation  and  ureteritis  of  left.  Chronic  cystitis, 
catarrhal  and  interstitial. — Left  kidney.  Abnormal  adhesions  cf  fatty 
to  fibrous  capsule  ;  the  latter  was  moderately  attached  to  the  surface 
of  the  kidney,  but  sufl&ciently  so  to  remove  small  portions  of  the  cortex 
46 


722  DISEASES    OF    THE    URETHRA. 

on  stripping.  The  kidney  measured  five  inches  in  length,  one  inch 
and  a  half  in  thickness,  and  one  inch  and  three-quarters  in  width. 
The  surface  was  lobulated,  the  siimmits  of  the  lobules  were  pale  yel- 
low, and  the  depressed  portion  reddish  in  color.  On  the  posterior 
surface  three  or  four  depressions  were  formed  by  falling  in  of  the 
kidney  substance.  A  section  showed  lai-gely  dilated  pelvis  and 
calyces,  with  resulting  atrophy  from  pressure  of  the  parenchyma  of 
the  organ.  This  condition  was  specially  marked  at  either  end,  and 
on  the  posterior  surface.  The  structure  at  the  upper  portion  of  the 
kidney  was  only  about  two  lines  in  thickness,  and  at  the  lower  end 
about  three  lines.  The  pelvis  and  calyces  contained  a  small  amount 
of  vellowish-brown  puriform  liquid  of  an  offensive  urinous  odor.  The 
walls  of  the  pelvis  and  calyces  were  slightly  thickened,  and  the 
mucous  membrane  presented  evidence  of  an  intense  pyelitis,  with- 
small  patches  of  pseudo-membrane,  mostly  found  in  the  dilated  calyces. 
The  greater  portion  of  the  kidney  was  markedly  atrophied,  except  two 
or  three  pyramids,  in  the  central  portion,  which  still  remained  of  com- 
paratively normal  size.  Here  the  pyramids  and  cortical  substance 
were  of  pale  yellowish  color,  the  columns  of  tubules  were  much  swol- 
len. The  compressed  poi-tions  showed  traces  of  pyramid  and  cortex 
only.- 

The  left  ureter  was  one-half  inch  in  diameter  throughout,  and  partly 
filled  with  the  same  material  as  found  in  the  pelvis.  It  contained 
detached  particles  of  pseudo-membrane  from  the  calyces.  The  coats 
were  hypertrophied,  especially  the  muscular  one,  and  the  mucous 
membrane  presented  evidence  of  chronic  ureteritis. 

Right  kidney.  There  were  firm  adhesions  of  the  fatty  to  the  fibrous 
capsule,  and  it  was  impossible  to  remove  the  latter.  This  kidney  was 
four  inches  long,  one  inch  and  three-quarters  wide,  and  one  inch  and 
a  half  thick.  It  presented  a  lobulated  appearance,  and  gave  on  the 
surface  a  marked  sense  of  fluctuation,  except  as  to  one  nodule,  on  the 
outer  border,  which  was  hard.  A  section  showed  the  kidney  to  have 
been  the  seat  of  an  encapsulated  pyo-nephrosis.  The  dilated  calyces 
Avere  filled  with  a  semifluid  cheesy  pus.  The  solid  portion  noted  was 
a  cretaceous  cheesy  mass,  encapsulated.  The  pelvis  is  obliterated, 
and  its  site  occupied  by  condensed  adipose  tissue. 

The  right  ureter  was  occluded  at  the  commencement,  and  traced 
into  a  cicatricial  mass  on  the  pelvis.  The  whole  ureter  was  atro- 
phied, and  its  canal  impervious,  except  for  a  short  distance  in  the 
upper  portion.  Its  vesical  termination  was  involved  in  a  firm,  radi- 
ating pigmented  cicatrix. 

The  bladder  was  contracted,  empty,  and  its  capacity  less  than  half 
an  ounce.  Its  walls  were  hypertrophied  at  the  base  and  neck,  while 
the  fundus  was  atrophied.  Evidence  of  chronic  interstitial  cystitis, 
with  streaks  of  connective  tissue  between  muscular  bundles.  The 
sutures  were  still  in  the  edges  of  the  fistula,  but  no  union  had  taken 
place.  The  mucous  membrane  showed  all  the  evidences  of  chronic 
cystitis. 

The  urethra  was  nearly  one-half  inch  in  diameter.      Its  raucous 


IMPORTANCE    OF    EXAMINING    THE    URINE.  723 

mcml)rane  was  thickened  and  pigmented.  About  one-(inarter  of  an 
inch  bcdow  the  vesical  orifice  three  or  four  deep  pockets  of  mucous 
membrane  were  found,  which  resembled  hernias  of  the  mucous  mem- 
brane from  rupture  of  the  muscular  coats,  and  were  evidently  the 
result  of  laceration  attending  dilatation  of  the  canal. 

Death  in  this  case  was  undoubtedly  hastened  by  the  anaesthetic, 
which  had  been  used  in  the  absence  of  any  evidence  of  kidney  dis- 
ease, so  far  as  could  be  determined  by  the  aid  of  the  microscope.  The 
experience  in  this  case  has  impressed  me  with  the  necessity  of  using 
the  ophthalmoscope  as  a  diagnostic  aid.  With  this  instrument  changes 
in  the  circulation  of  the  retina  can  often  be  detected  where  the  in- 
dividual has  suffered  for  any  length  of  time  from  Bright's  disease. 

In  the  advanced  stages,  the  microscope  cannot  be  relied  upon  alone, 
since  the  secreting  portions  of  the  kidney  may  have  been  destroyed 
to  such  an  extent  that  no  greater  number  of  casts  would  be  presented 
than  at  an  earlier  period  of  the  disease.  It  is  ahvays  advisable  to 
make  a  microscopic  examination,  but  before  doing  so  diuretics  should 
be  administered  for  the  purpose  of  increasing  temporarily  the  action 
of  the  kidneys.  If  it  be  possible  to  accomplish  this,  casts  and  other 
evidence  of  disease  will  be  thrown  off  in  larger  quantities  under  this 
stimulated  action  than  would  occur  from  the  ordinary  functioning  of 
the  organ.  Several  specimens  of  urine  should  be  examined  in  the  same 
order  as  excreted.  If  the  kidneys  are  healthy  no  effects  leading  to 
suspicion  of  disease  would  be  produced  by  this  increased  action.  In 
the  early  stages  of  Bright's  the  evidences  of  disease  would  be  the 
more  likely  to  lessen  under  the  same  influence,  while,  if  the  disease 
were  already  far  advanced  they  would  be  increased. 


'2J:  CYSTITIS. 


CHAPTER    XXXV. 

CYSTITIS.     STO^'E  IN  THE  BLADDER  A^'D  L'RETEES. 

This  disease  is  so  insidious  in  its  course,  and  has  its  origin  in  so 
many  different  causes,  that  it  is  frequently  far  advanced  before  it  is 
recognized.     The  chief  exciting  causes  are  : — 

Exposure  to  cold,  resulting  either  in  inflammation  of  the  bladder  it- 
self or  in  the  neighborhood ;  direct  violence ;  neglect  in  emptying  the 
bladder  during  parturition ;  the  habit  of  long  retention  of  the  urine ; 
too  early  closure  of  a  vesico-vaginal  fistula,  before  the  tissues  have 
regained  a  healthy  condition ;  different  displacements  of  the  uterus 
acting  as  mechanical  sovirces  of  irritation ;  fissure  in  ano  and  hemor- 
rhoids ;  some  forms  of  dyspepsia  in  which  the  urine  becomes  irritating ; 
polypi  or  other  growths  ;  and  ulcerations  in  the  urethra. 

Other  causes  exist  by  which  a  continued  irritability  of  the  bladder 
may  be  kept  up  until  Avhat  is  generally  termed  chronic  cystitis  be- 
comes established,  but  it  is  unnecessary  to  enumerate  them. 

"When  resulting  from  exposure  or  from  violence,  the  whole  mucous 
membrane  may  become  inflamed  from  the  beginning  of  the  attack, 
constituting  a  catarrh  of  the  bladder. 

But  the  initial  point  of  irritation  is,  as  a  rule,  at  the  neck  of  the 
bladder,  and  the  lining  membrane  of  the  viscus  proper  does  not  become 
involved  until  at  a  comparatively  late  stage  of  the  disease. 

A  poor  woman  may  not  have  had  the  attention  of  a  physician 
during  a  prolonged  labor,  and  her  bladder  may  remain  unemptied 
sometimes  for  days.  The  bladder  must  rise  in  the  abdomen  as  the 
accumulation  goes  on,  and  a  continued  traction  is  thus  exerted  on  the 
neck  of  the  bladder  as  it  is  dragged  from  under  the  arch  of  the  pubis. 
Inflammation  is  established  which  does  not  subside  after  the  bladder 
has  been  emptied,  but  continues  to  excite  a  frequent  desire  to  urinate. 
As  a  consequence  of  the  straining  effort  to  force  out  each  drop  of 
urine,  a  crack,  or  fissure,  frequently  forms  at  the  bottom  of  one  of  the 
folds  of  loose  tissue  about  the  neck  of  the  bladder. 

Whenever  the  uterus  is  completely  retroverted,  the  cervix  is  either 
left  pressing  directly  against  the  neck  of  tlic  bladder,  or  it  is  dragged 


SYMPTOMS.  725 

upward  and  backward.  If  the  uterus  is  too  large  and  sags  in  the 
pelvis,  or  if  the  upper  portion  of  the  vagina  is  relaxed,  or  the  peri- 
neum lost,  so  as  to  no  longer  furnish  support,  an  irritation  will  be 
excited.  Whenever  the  uterus  is  anteverted  and  enlarged  so  as  to 
prolapse,  the  effect  will  be  the  same.  It  has  been  shown  in  the 
chapter  on  displacements  that  whenever  the  uterus  reaches  a  certain 
point  of  prolapse,  the  whole  weight  is  suspended  from  the  neck  of  the 
bladder.  This  excites  a  constant  desii'e  to  empty  the  bladder,  but  as 
no  relief  follows,  the  constant  effort  in  time  gives  rise  to  a  painful 
tenesmus. 

From  whatever  exciting  cause  the  difficulty  may  arise,  the  bladder 
long  remains  a  patient  sufferer  before  it  becomes  seriously  diseased. 
In  the  beginning  a  profuse  local  secretion  takes  place,  especially  if 
the  urine  be  markedly  phosphatic,  and  mucous  accumulations  follow. 
At  first  the  urine  is  to  a  great  extent  evacuated,  but,  in  time,  the 
frequent  efforts  to  force  out  the  mucus  induce  inflammation  and  thick- 
ening at  the  neck  of  the  bladder.  As  a  consequence,  a  certain  amount 
of  stale  urine  is  always  retained,  thus  increasing  the  irritation.  At 
length  the  vesical  walls  become  thickened,  the  mucous  membrane  ul- 
cerated, infiltration  of  urine  to  some  extent  occurs,  abscesses  form,  and 
pelvic  cellulitis  is  not  an  infrequent  result.  Long  ere  this  the  oede- 
matous  and  thickened  tissues  have  so  greatly  obstructed  the  mouth  of 
the  ureters  that  the  urine  can  no  longer  flow  freely  into  the  bladder. 
The  ureters  often  become  enormously  distended,  the  inflammation 
extends  along  them  to  the  kidneys,  these  organs  at  length  become  dis- 
organized by  the  accumulation  of  urine,  and  death  ultimately  results 
from  ursemic  poisoning.  Before  the  last  stage  of  the  disease  has  been 
reached,  the  poor  woman  has  experienced,  through  a  series  of  years, 
an  amount  of  suffering  both  of  body  and  mind  unequalled,  I  believe,  in 
any  other  infirmity  to  which  humanity  is  subject.  To  alleviate  this 
suffering,  these  women  soon  become  addicted  to  the  use  of  opium,  and 
it  is  almost  incredible  to  what  degree  of  tolerance  to  this  drug  they 
may  attain.  I  have  frequently  noticed  a  tendency  to  a  mucous  diarrhoea 
which  could  be  attributed  only  to  the  excessive  use  of  opiates ;  and  the 
frequent  desire  to  evacuate  the  bowels  greatly  aggravates  the  condition 
of  the  bladder. 

Before  considering  the  proper  mode  of  treatment  let  us  briefly  enu- 
merate the  chief  anatomical  points  with  which  it  is  important  that  we 
should  be  familiar. 

On  looking  into  the  bladder  from  above,  it  will  be  noticed  that  from 


726  CYSTITIS. 

all  directions  the  parts  converge  towards  a  space  at  tlie  bottom  which 
is  near  the  base  of  the  bladder. 

The  base  proper  of  the  bladder  may  be  represented  as  a  triangle,  the 
mouths  of  the  ureters  being  situated  at  each  extremity  of  the  base,  and 
the  vesico-urethral  orifice  at  the  apex.  This  triangular  space  maps  out 
the  surface  where  the  bladder  and  vagina  are  in  the  closest  contact ; 
elswhere  they  are  connected  by  cellular  tissue.  Just  outside  of  the 
line  of  the  ureters,  in  the  sulcus  on  each  side,  run  the  larger  blood- 
vessels to  and  from  the  lower  portion  of  the  uterus  and  neighboring 
parts.  I  have  made  a  number  of  post-mortem  examinations  of  the 
healthy  bladder,  both  in  situ  and  after  the  removal  of  the  pelvic  organs, 
and  in  no  instance  have  I  found  the  distance  from  the  mouth  of  one 
ureter  to  the  other,  or  from  either  to  the  orifice  of  the  urethra,  greater 
than  an  inch,  the  space  thus  included  forming  a  triangle  of  equal  sides. 
When  disease  has  existed  and  the  bladder  has  been  long  contracted, 
the  distance  between  these  points  in  all  probability  is  somewhat  les- 
sened. In  a  cross  section,  except  at  the  base,  the  vagina  and  bladder 
occupy  to  each  other  about  the  same  relation  as  two  cylindrical  bodies 
would  do  when  placed  in  contact.  This  anatomical  relation  must  be 
fully  appreciated  in  its  bearing  on  the  mode  of  operation  to  be  practised 
for  the  relief  of  cystitis. 

The  female  bladder  has  no  sphincter  proper,  and  the  retentive  power 
is  chiefly  due  to  the  loose  superabundant  tissue  about  the  neck, 
which  falls  together  in  a  number  of  folds.  As  the  urine  accumulates 
the  bladder  rises  in  the  pelvis  and  the  retentive  power  is  increased  by 
the  urethra  being  drawn  up  against  the  arch  of  the  pubes.  When  the 
bladder  becomes  very  much  distended,  these  folds  all  disappear  in  the 
dilatation,  and  the  urine  dribbles,  although  the  woman  may  be  unable 
to  empty  the  bladder  on  account  of  the  traction  on  the  urethra  under  the 
pubes.  But  as  the  healthy  bladder  beomes  moderately  distended  and 
lifted  in  the  pelvis  the  lower  portion  assumes  a  funnel  shape.  The 
action  of  the  abdominal  muscles  then  has  the  effect  of  concentrating 
the  pressure  on  the  column  of  urine  ui'ging  it  into  the  neck  or  nozzle, 
and  the  cavity  is  rapidly  emptied  without  notable  effort.  When  in- 
flammation has  occurred  this  great  mobility  of  the  parts  is  lost,  and  it 
requires  more  of  an  effort  to  empty  the  bladder.  The  shape  of  the 
viscus  changes  under  the  influence  of  disease  so  as  to  resemble  more 
that  of  the  male  bladder,  somewhat  of  a  pouch  forming  in  the  posterior 
portion,  thus  admitting  of  the  retention  of  more  or  less  urine  which 
may  decompose  and  add  to  the  difficulty. 


TREATMENT.  727 

Treatment. — As  long  as  the  case  is  one  of  irritation  of  the  bladder, 
due  to  some  exciting  cause  which  can  be  recognized,  and  the  micro- 
scope fails  to  disclose  evidence  of  pus  or  of  casts  from  the  kidneys, 
we  may  delay  any  surgical  procedure. 

"We  must  first  operate  on  any  fissure  or  hemorrhoids  that  may  exist. 
If  necessary  a  pessary  may  be  fitted  to  lift  the  uterus  from  the  floor  of 
the  pelvis,  even  if  in  so  doing  the  organ  becomes  more  anteverted,  for 
relief  will  be  obtained  when  the  neck  of  the  bladder  is  relieved  of  the 
weight.  At  the  same  time  the  instrument  must  be  so  shaped  in  front 
as  to  avoid  all  pressure  on  the  urethra.  If  the  upper  portion  of  the 
vagina  be  over-stretched  so  as  to  allow  of  prolapse,  relief  may  be  gained 
from  some  modification  of  the  operation  for  procidentia,  by  which  the 
excess  of  vaginal  tissue  is  turned  in  and  allowed  to  retract.  With  partial 
or  complete  cystocele  or  rectocele,  the  appropriate  operation  at  the 
vaginal  wall  will  be  necessar}^,  as  well  as  closure  of  the  perineum. 

In  the  local  treatment  of  the  bladder  the  main  dependence  rests  in 
the  frequent  and  pi'oper  manner  of  washing  out  the  cavity.  This 
operation  the  surgeon  should  perform  himself,  if  possible,  using  simply 
warm  water  in  large  quantities  to  be  introduced  by  means  of  a  siphon 
syringe,  placed  at  a  certain  height,  or  injected  from  a  Davidson's 
syringe  with  great  care,  using  a  double  catheter  for  whichever  instru- 
ment is  employed.  After  the  injection,  if  the  pain  has  been  increased, 
it  will  be  diminished  greatly  by  a  solution  of  morphine  thrown  into  the 
bladder.  Although  the  absorbing  power  of  the  bladder  is  very  limited 
in  a  healthy  state,  yet  in  this  condition  it  is  sufficient  to  be  sensibly 
affected  by  the  anodyne.  When  the  injection  of  water  cannot  be  borne 
without  increasing  the  irritation  of  the  bladder,  or  where  there  had 
been  no  marked  improvement  in  the  case  after  a  reasonable  time,  a 
surgical  operation  must  be  resorted  to.  This  consists  in  making  an 
opening  in  the  vesico-vaginal  septum  through  which  the  urine  may 
escape  into  the  vagina,  as  rapidly  as  it  enters  the  bladder.  In  this 
way  absolute  rest  of  the  organ  is  secured  and  the  inflammation  will 
subside.  The  patient  should  be  given  the  option  of  submitting  to  the 
operation  or  not,  being  assured  that  there  is  a  reasonable  hope  of 
success  on  the  one  hand,  or  on  the  other  inevitable  death  from  exten- 
sion of  the  disease  to  the  kidneys.  Many  objections  have  been  made 
to  surgical  interference  in  these  cases.  The  chief  danger  is  in  the 
involvement  of  the  kidneys,  and  this  has  been  entirely  overlooked, 
the  exceptions  taken  being  based  on  theoretical  grounds  alone. 
The  advance  to  be  made  in  the  future  will  render  apparent  the  neces- 
sity for  an  early  resort  to  the  operation  before  permitting  a  compara- 


728  CYSTITIS. 

tively  simple  condition  to  pass  beyond  the  reach  of  any  remedial  means 
yet  known  to  the  profession. 

In  the  Avinter  of  1858  I  removed,  through  an  artificial  opening 
made  in  the  vesico-vaginal  septum,  a  calculus  from  the  bladder  of  a 
patient  in  the  Woman's  Hospital.^  She  had  been  an  inmate  of  the 
institution  several  years  before  with  a  vesico-vaginal  fistula,  which 
was  closed  previous  to  her  discharge.  As  the  bladder  was  in  a  dis- 
eased condition,  by  the  advice  of  Dr.  Sims,  the  artificial  opening  was 
left  for  the  greater  facilitv  afforded  in  the  treatment  for  restorino-  the 
organ  to. a  healthy  state.  This  idea  was  a  new  one  to  me  at  that  time, 
and  to  Dr.  Sims,  I  believe,  is  due  the  credit  of  the  mode  of  treatment 
for  cystitis  in  the  female  resulting  from  stone. 

While  temporarily  in  charge  of  the  Woman's  Hospital,  during  the 
summer  of  1861, 1  performed  this  operation  with  the  \iew  of  securing 
to  the  bladder  rest  from  persistent  tenesmus,  in  a  long-standing  case 
of  cystitis  following  exposure.  I  was  assisted  by  Prof.  James  P. 
White,  of  Bufialo,  and  at  a  meeting  of  the  Xew  York  Obstetrical 
Society,  in  December,  18T0,  when  he  was  present  as  an  invited  guest, 
the  doctor  stated  the  fact,  and  that  he  happened  also  to  be  present  at 
the  final  closure.  The  idea  at  the  time  was  supposed  to  be  original, 
and  that  it  was  the  first  case  of  cystitis  in  the  female  in  which  the 
bladder  had  been  opened  for  the  specific  purpose  of  obtaining  rest,  and 
as  a  distinct  procedure  in  the  course  of  treatment.  So  clear  were  my 
views  that  to  the  present  day  there  has  been  no  modification  of  the 
plan  as  carried  out  in  the  first  case. 

Dr.  AVillard  Parker,  of  this  city,  presented  at  the  annual  meeting  of 
tie  New  York  State  Medical  Society  for  1867  a  paper  on  "  Cystitis  and 
Rupture  of  the  Bladder  treated  by  Cystotomy,"  which  was  published 
in  the  Transactions  for  that  year.  He  states  that  on  Jan.  3,  1846, 
he  performed  lithotomy  on  a  male  when  he  Avas  unable  to  remove  the 
stone,  but  the  cystitis  was  relieved  by  the  free  escape  of  the  urine 
through  the  opening.  At  the  end  of  three  months  a  fresh  attack  of 
cystitis  came  on,  the  kidneys  became  involved,  and  death  resulted. 
This  case  seems  to  have  been  instrumental  in  drawing  his  attention  to 
the  subject.  Nov.  23,  1850,  Prof.  Parker  operated  at  Bellevue  Hos- 
pital on  a  case  of  chronic  cystitis  in  the  male.     He  states  :^  "  The 

'  The  history  of  the  operation,  as  given  in  this  chapter,  has  been  taken  from  a 
paper,  "  Chronic  Cystitis  in  the  Female  and  Mode  of  Treatment,"  as  read  by  me 
before  the  State  Medical  Society,  and  published  in  the  American  Practitioner  for 
Feb.  1872. 

2  New  York  Medical  .Journal,  1851,  vol.  vi.,  as  reported  by  Stephen  Smith,  M.D., 
Assistant  Surgeon  to  the  Hospital. 


CYSTOTOMY.  729 

object  in  view  was  to  open  a  channel  hj  Avhich  the  urine  could  drain 
oft"  as  fast  as  secreted,  and  thus  afford  rest  to  the  bladder,  the  first 
essential  indication  in  the  treatment  of  inflammation."  The  concep- 
tion of  treatment  was  perfect,  and  there  has  been  no  later  advance 
made  in  the  pathology.  The  patient  died  in  a  few  days,  and  the 
autopsy  revealed  the  fact  that  the  kidney  had  undergone  degenera- 
tion. Although  a  favorable  result  was  not  attained,  it  clearly  estab- 
lishes Dr.  Parker's  claims  to  priority  for  this  mode  of  treatment  of 
cystitis  in  the  male. 

Previous  to  the  reading  of  this  paper,  before  the  State  Society  in 
1867,  I  had  been  ignorant  of  Dr.  Parker's  views  on  this  subject,  and 
was  unable,  until  several  years  after,  to  obtain  a  copy  of  the  journal 
in  which  the  case  was  printed  before  I  became  a  practitioner  in  New 
York. 

In  July,  1868,  I  published  my  work  on  Yesico- Vaginal  Fistula, 
containing  the  histories  of  several  cases  of  cystitis  which  had  been 
treated  by  making  an  opening  for  the  free  escape  of  urine. 

At  the  meeting  of  the  State  Society,  Feb.  7,  1871,  Dr.  Bozeman 
presented  a  paper  on  "  Urethrocele,  Catarrh,  and  Ulceration  of  the 
Bladder  in  Females,"  which  was  published  in  the  New  York  Journal 
of  Obstetrics  for  Feb.  1871. 

Dr.  Bozeman  details  the  history  and  successful  result  of  an  opera- 
tion for  the  relief  of  cystitis,  performed  January,  1861,  the  artificial 
opening  having  been  closed  the  following  June.  The  patient  was  cured, 
and  nine  years  afterwards  there  had  been  no  return  of  the  disease. 
It  is  stated  :  "  To  Prof.  Willard  Parker  is  due  the  suggestion  of  open- 
ing the  male  bladder  for  the  relief  of  catarrh,  and  this  encouraged  me 
to  extend  the  practice  to  the  female  bladder,  as  I  have  described.  Dr. 
Emmet  and  other  American  svxrgeons  have  since  adopted  the  practice 
in  case  of  vesical  catarrh  in  the  female,  and  I  doubt  not  with  equal 
success."  .  .  .  "Delay  in  the  report  of  my  case  of  ulceration  was 
due  to  the  suspension  of  all  medical  journals  in  the  South  during  the 
war,"  etc.  This  statement  is  unfortunately  calculated  to  giv^e  the 
impression  that  the  American  surgeons  who  have  practised  this  mode 
of  treatment  since  1861  were  indebted  to  Dr.  Bozeman.  With  all 
due  respect  for  his  claims,  this  is  not  correct,  for,  until  his  paper  was 
presented,  he  gave  the  profession  no  opportunity  of  knowing  that  he 
had  ever  operated.  He  has  certainly  not  done  justice  to  himself  in  so 
long  withholding  his  claims,  and  he  can  scarcely  be  ignorant  that  this 
operation  has  been  the  practice  at  the  Woman's  Hospital  previous  to 
and  from  the  time  of  his  coming  to  New  York,  immediately  after  the  war. 


730  CYSTITIS. 

In  the  case  upon  which  I  operated  in  1861  the  opening  soon  closed, 
and  with  its  closure  no  further  improvement  in  the  condition  of  the 
patient  took  place.  I  shortly  afterwards  made  a  larger  opening 
through  which  the  urine  freely  escaped.  Ten  months  later  I  closed 
the  artificial  opening,  as  the  thickened  condition  of  the  bladder  had 
then  disappeared.  I  have  never  seen  a  case  of  disease  of  the  bladder 
so  extensive  as  this  was,  without  the  coexistence  of  kidney  trouble. 
The  mucous  membrane  of  the  bladder  had,  to  a  great  extent,  been 
lost,  and  the  walls  had  become  so  hypertrophied  that  the  bladder,  as 
a  hard  mass,  could  be  felt  contracted  behind  the  pubes,  and  was 
exceedingly  tender  on  pressure.  This  case  had  been  of  many  years' 
standing,  and  her  suffering  had  made  a  wreck  of  both  body  and  mind. 
She  was  perfectly  cured,  and  came  under  observation  frequently  imtil 
about  1869,  since  which  time  I  have  lost  sight  of  her. 

Case  L. — During  the  autumn  of  1862,  shortly  after  her  arrival  in 
this  country,  an  English  Avoman,  suffering  from  cystitis,  Avas  admitted 
to  the  Woman's  Hospital.  She  refused  to  submit  to  any  surgical  pro- 
cedure, and  shortly  afterwards  died  in  consequence  of  the  diseased 
condition  of  the  kidneys.  (I  mention  the  case  because  she  had  been 
for  som.e  time  under  the  care  of  Sir  James  Y.  Simpson  previous  to 
leaving  Great  Britain,  and  the  chief  objection  made  to  me  and  others 
against  an  operation  was  that  so  high  an  authority  as  Prof.  Simpson 
had  never  intimated  the  necessitj^  for  such  a  procedure.  The  credit 
of  this  mode  of  treatment  has  been  recently  claimed  for  Prof.  Simpson 
by  Mr.  Lawson  Tait.  Whether  the  idea  after  this  date  occurred  to  him, 
or  that  he  was  really  indebted  to  this  country  for  it,  is  of  little  conse- 
quence. But  by  this  case  the  fact  is  proved  that  previous  to  the  svim- 
mer  of  1862  he  was  ignorant  of  the  method,  and  treated  his  cases 
simply  by  injection  into  the  bladder.) 

Case  LI. — About  14  years  ago,  in  my  private  hospital,  I  closed  the 
lacerated  perineum,  of  a  woman,  who  seemed  otherwise  in  excellent 
health,  and  was  sent  to  me,  I  believe,  by  Dr.  Varick,  of  Jersey  City. 
Ether  was  administered,  but  she  never  regained  entirely  her  conscious- 
ness, and  died  with  well-marked  symptoms  of  umemic  poisoning  about 
32  hours  after  the  operation.  It  was  found  that  she  had  Bright's 
disease,  both  kidneys  being  so  involved,  that  the  secretion  of  urine 
was  arrested,  and  only  a  drachm  or  two  was  found  in  the  bladder. 

This  case  was  reported,  and  in  the  report  I  called  the  attention  of 
the  profession  to  the  greater  necessity  for  examining  the  condition  of 
the  kidneys  than  that  of  the  heart.  Since  then  I  have  had  at  least 
five  deaths  to  occur  from  umemic  poisoning  in  public  and  private  prac- 
tice, and  these,  perhaps,  might  not  have  occurred,  if  my  assistants  had 
been  able  to  examine,  or  had  appreciated  the  importance  of  examining, 
the  urine  before  the  anaesthetic  was  given. 


CYSTOTOMY.  781 

I  estaWishcrl  the  rule,  when  in  charge  of  the  Woman's  Hospital, 
that  the  urine  should  be  examined  in  every  case  before  an  an<iesthetic 
was  administered.  The  result  was  that  in  a  number  of  instances 
unsuspected  disease  of  the  kidneys  was  detected,  and  the  operation 
was  performed  with'  the  aid  of  opium,  and  without  an  anassthetic. 

To  the  effects  of  the  anaesthetic  I  attribute  the  chief  danger  attend- 
ing the  operation  in  the  advanced  stages  of  cystitis,  although,  on 
account  of  the  hypersensitive  state  of  the  bladder,  it  is  almost  indis- 
pensable ;  Avhen  the  kidneys  are  barely  able  to  perform  their  function 
sufficiently  well  to  preserve  life,  there  is  great  danger  in  imposing 
additional  work  upon  them,  and,  whenever  they  fail,  death  from  urae- 
mia must  rapidly  follow. 

It  has  been  denied  that  the  kidneys  take  an  active  part  in  the  elimi- 
nation of  ether  from  the  blood,  but  I  am  convinced  that  this  view  is 
incorrect.  Hours  after  having  performed  some  prolonged  operation  I 
have  often  detected  in  my  own  urine  the  smell  of  ether  which  had 
been  used.  I  have  had  no  experience  with  the  use  of  any  other  anaes- 
thetic in  this  condition,  but  on  theoretical  grounds  would  consider  the 
use  of  the  nitrous  oxide  as  the  least  objectionable,  and  particularly  as 
the  operation  is  one  of  so  short  duration.  Unfortunately  we  cannot 
judge  in  any  case  of  long  standing  as  to  the  actual  condition  of  the 
kidneys,  so  that  the  consequences  which  may  follow  must  be  fully  ap- 
preciated both  by  the  operator  and  the  patient. 

The  operation  as  practised  for  the  relief  of  cystitis  is  in  itself  a 
simple  one,  and  if  resorted  to.  before  the  disease  has  advanced  so  far 
as  to  involve  the  kidneys,  is  as  free  from  risk  as  any  in  minor  surgery. 
Even  under  the  more  unfavorable  circumstances  the  risk  of  the  opera- 
tion is  justifiable,  for  by  it  life  may  be  prolonged,  and  a  great  degree 
of  comfort  obtained  in  allaying  the  persistent  efforts  to  empty  the 
bladder. 

The  operation  is  to  be  performed  under  the  inflvience  of  an  anaes- 
thetic when  possible,  with  the  patient  on  the  left  side,  and  the  ante- 
rior wall  of  the  vagina  fully  exposed  by  means  of  a  large-sized  Sims' s 
speculum.  A  sound  somewhat  abruptly  curved  an  inch  and  a  half 
from  its  extremity,  must  be  introduced  into  the  bladder  and  held  by  an 
assistant.  While  the  point  of  this  instrument  is  firmly  pressed  in  the 
median  line  against  the  base  of  the  bladder,  a  little  behind  the  neck, 
the  projecting  tissue  on  the  vaginal  surface  must  be  seized  with  a 
tenaculum,  and  divided  by  a  pair  of  scissors  directly  on  the  point  of 
the  sound  until  it  can  be  passed  through  into  the  vagina.  With  the 
sound  remaining  in  the  opening  as  a  guide,  one  blade  of  a  pair  of 


732  CYSTITIS. 

scissors  should  be  passed  into  the  bladder,  and  the  vesico-vaginal 
septum  be  divided  backward  in  the  median  line.  By  this  mode, 
especially  where  the  vagina  is  of  a  natural  size,  the  operation  is  ex- 
tremely simple,  and  is  completed  in  a  few  moments.  The  object  in 
cutting  on  the  point  of  the  sound  is  to  be  sure  that  the  bladder  and 
vaginal  surface  are  divided  in  corresponding  incisions,  for  there  is  so 
much  mobility  of  one  surface  over  the  other  that  it  is  exceedingly 
difficult  to  enter  the  bladder  unless  the  parts  are  transfixed. 

The  mode  of  operating,  as  described,  can  be  but  little  improved 
upon  as  to  simplicity.  The  median  line  has  been  preferred  for  the 
location  of  the  incisions,  since  it  is  not  likely  to  include  any  large 
bloodvessels,  unless  the  opening  be  extended  too  near  to  the  cervix 
uteri,  or  to  the  neck  of  the  bladder.  In  theory,  there  is  no  necessity 
for  an  opening  larger  than  that  equal  to  the  area  of  the  two  ureters ; 
in  practice,  however,  it  is  found  that  it  must  be  greater  at  first  than 
this,  from  the  fact,  that,  in  spite  of  all  the  care  that  can  be  taken 
to  prevent  it,  a  large  portion  of  it  Avill  close  too  soon.  Moreover, 
at  first  it  is  a  great  advantage  to  have  an  ample  opening  through 
which  the  accumulated  mucus  in  the  bladder  may  be  easily  washed 
out.  It  is  very  seldom  that  much  bleeding  follows  this  operation 
unless,  as  just  stated,  the  incision  is  extended  too  far  in  either 
direction.  When  a  large  vessel  has  been  divided,  it  will  either  be  a 
branch  of  the  circular  artery  of  the  cervix  uteri,  or  one  given  off  from 
the  subpubic  artery.  Bleeding  in  either  direction  is  readily  arrested 
by  introducing  a  silver  suture,  so  as  to  include  a  fair  amount  of  tissue 
beyond  the  angle  of  the  wound,  and  twisting  it  sufficiently  tight. 
The  suture  must,  of  course,  be  bent  flat  in  accordance  with  directions 
given  in  an  earlier  part  of  this  book,  so  that  it  shall  not  be  an  addi- 
tional source  of  irritation. 

Dr.  Bozeman  recommends  the  cutting  out  of  a  circular  piece,  and 
the  plan  is  a  good  one,  for  the  opening  could  then  never  entirely  close 
of  itself.  But  the  size  of  the  piece  as  recommended  by  him  is  too 
large  for  any  one  but  an  expert  to  remove.  The  general  operator 
must  bear  in  recollection  the  anatomy  of  the  parts,  and  remove  but  a 
moderate  sized  portion,  or  he  will  be  apt  to  include  the  mouths  of 
both  ureters,  the  neck  of  the  bladder,  and  to  open  laterally  into  the 
large  bloodvessels  running  along  the  vagina  outside  of  the  bladder. 

Various  means  have  been  resorted  to  for  the  purpose  of  keeping 
the  artificial  opening  patulous.  I  have  used  in  some  cases  with 
advantage  a  stud,  or  eyelet,  made  from  glass  tubing  half  an  inch  in 


CYSTOTOMY. 


.733 


Fig.  117. 


Emmet's  cystitis 
eyelet. 


diameter,  and  not  unlike  a  spool  in  shape,  which  is 
buttoned  into  the  slit.  The  portion  of  the  flange  to 
remain  within  the  bladder  requires  to  be  but  little 
more  than  a  slight  flare,  with  tlie  edge  turned  over  to 
keep  the  instrument  in  place,  while  the  vaginal  rim 
may  be  larger  to  prevent  its  slipping  into  the  blad- 
der. It  will  remain  loose,  and  with  sufficient  play  to 
prevent  the  parts  from  healing  up  too  tightly  around 
it.  For  its  removal  only  a  pair  of  forceps  is  necessary,  by  which  one 
side  may  be  turned  up  for  the  other  to  escape.  If  used  it  should  be 
made  light,  and  only  from  the  finest  quality  of  Bohemian  glass.  It  is 
really  a  most  useful  instrument,  but  I  have  been  obliged  to  abandon 
it  on  account  of  the  difficulty  of  having  them  made  from  a  proper 
quality  of  glass.  If  the  least  amount  of  lead  or  any  other  impurity 
exists  in  the  glass,  it  will  in  a  few  hours  become  encrusted  Avith  a 
sabulous  deposit  from  the  urine,  and  will  increase  greatly  the  irri- 
tation. As  a  rule,  therefore,  I  think  it  advisable  at  first  to  rely  upon 
the  careful  introduction  of  the  finger  night  and  morning,  but  after  a 
few  days,  when  the  irritation  of  the  parts  has  somewhat  subsided,  the 
urine  is  in  better  condition,  and  the  incision  beginning  to  close,  the 
glass  stud  may  be  used  Avith  greater  advantage.  As  a  substitute  for 
the  button.  Dr.  Bache  Emmet,  one  of  the  assistant  surgeons  to  the 
Woman's  Hospital,  has  employed  a  glass  instrument  of  the  shape  and 
size  represented  in  Fig.  118,  by  which  the  urine  is  conducted  to  the 
vaginal  outlet.     It  is  introduced  with  less  difficulty  than  the  eyelet, 


Fig.  118. 


Bache  Emmet's  fistula  tube. 

and  in  many  cases  it  answers  better,  especially  where  it  is  advisable 
to  keep  the  urine  out  of  the  vagina  and  from  recently  cut  surfaces, 
and  it  answers  Avell  while  the  patient  is  remaining  quiet  in  bed. 

Prof.  Fallen  recommends  opening  into  the  bladder  with  the  Faque- 
lin  thermo-caut^re  as  follows:^ — 


'  Kolpo-cystotomy,  or  Artificial  Vesico-vaginal  Fistula,  by  Montrose  A.  Fallen, 
A.  M.,  M.D.,  etc.     Am.  Jour,  of  Obstetrics,  etc.,  vol.  xi.  April,  1878. 


73-i  CYSTITIS. 

"  The  main  difficulty  hitherto  has  been  to  keep  the  incision  open 
after  the  use  of  the  scissors  or  knife.  Artificial  means  must  be  re- 
sorted to,  such  as  an  India-rubber  tube  passed  from  the  urethra  through 
the  opening,  which  is  annoying  and  painful,  or  a  glass  button  intro- 
duced, which  is  difficult  to  retain,  and  when  retained  is  apt  to  beget 
vesical  tenesmus.  I  believe  the  use  of  the  actual  cautery  at  a  red  heat 
will  be  found  to  answer  all  pui'poses."  "If  the  platinum  tip  of  the 
cautery  be  heated  to  a  white  heat,  it  cuts  through  as  rapidly  as  the 
knife,  and,  therefore,  hemorrhage  is  to  be  expected.  Besides  the 
thin  slough  produced  by  white  heat  might  peal  off  and  union  ensue. 
To  avoid  both  bleeding  and  contraction,  the  tip  should  be  raised  to  a 
red  heat  only,  and  passed  slowly  along  the  side  of  the  proposed  open- 
ing, dividing  first  the  mucous  membrane  of  the  vagina,  and  then  held 
still  for  a  moment  or  so  to  allow  the  adjacent  vessels  to  contract  and 
become  occluded.  The  submucous  connective  tissue  is  then  burned, 
and  afterwards  the  bladder  wall  itself.  Extreme  delicacy  of  manipu- 
lation is  required  upon  the  part  of  the  surgeon,  lest  he  burn  directly 
into  the  cavity  of  the  bladder,  which  should  be  avoided  in  order  to 
prevent  hemorrhage,  contraction,  and  subsequent  union." 

I  have  had  no  experience  with  this  mode  of  treatment,  but  feel 
confident  that  without  the  greatest  delicacy  of  manipulation,  serious 
results  might  follow  its  use.  Should  the  bladder  be  contracted  as  it 
usually  is  in  these  cases,  the  fundus  might  be  in  such  close  proximity 
to  the  point  of  entrance  of  the  cautery  as  to  be  also  involved.  This 
objection,  however,  could  be  overcome  by  placing  the  patient  on  the 
knees  and  elbows,  and  by  introducing  a  catheter  into  the  bladder,  so 
that  it  may  be  dilated  by  atmospheric  pressure. 

I  am  inclined  to  advocate  the  use  of  the  cautery  to  the  extent  of 
applying  it  to  the  raw  edges  after  performing  the  operation  in  the 
usual  manner,  the  edges  being  rolled  out  with  a  tenaculum.  To 
use  it  might  prove  a  valuable  means  of  keeping  the  fistula  open. 
Contraction  to  a  great  extent  would  doubtless  take  place  afterwards, 
but  the  edges  would  be  in  a  condition  less  likely  to  be  irritated  by 
the  urine  after  the  slough  bad  been  thrown  off,  than  would  be  the  case 
with  surfaces  Avhich  had  just  been  denuded.  I  should  also  anticipate 
benefit  from  it  as  a  counter-irritant,  unless  the  cautery  were  so 
freely  applied  as  to  establish  a  degree  of  inflammatory  action  which 
could  not  be  limited  to  the  edges  of  the  wound. 

The  usual  routine  of  treatment,  in  a  general  way,  is  to  wash  the 
bladder  out  thoroughly  every  day  by  placing  the  patient  on  the  back 
with  a  bed-pan  under  her  hips.     Two  fingers  of  the  left  hand  of  the 


CASES.  735 

operator  must  press  back  the  perineum  -while  they  are  inserted  into 
the  fistulous  opening  to  separate  its  edges.  Large  quantities  of  \varm 
water  must  be  then  carefully  thro^vn  into  the  bladder  by  means  of  a 
Davidson's  syringe  held  in  the  other  hand.  The  smaller  nozzle  of  the 
instrument  Avill  be  the  most  useful,  and  may  be  introduced  either 
through  the  urethra  or  directly  into  the  opening.  Afterwards  the 
point  of  a  sound  must  be  drawn  along  the  angles  of  the  opening  to 
retard  its  closure. 

The  following  cases  are  given  in  detail,  to  illustrate  some  of  the 
difficulties  and  complications  which  attend  the  treatment: — 

Case  LII. — ^Irs.  B.,  aged  24  years,  was  admitted  to  the  hospital 
from  Goshen,  N.  Y.,  Oct.  17,  18G8,  with  a  vesico-vaginal  fistula  of 
four  months'  standing,  having  followed  a  labor  of  30  hours.  There 
had  been  an  extensive  loss  of  tissue,  and  after  three  operations  she 
was  discharged  cured,  March  31, 1869. 

A  few  weeks  after  her  discharge  she  began  to  suffer  from  irritation 
of  the  bladder.  This  increased,  and  occasionally  the  urine  was  mixed 
with  blood.  She  was  pregnant,  and  was  delivered  with  forceps  Feb. 
14,  1870.  Gradually  the  difficulty  with  the  bladder  became  greater, 
and  she  was  again  admitted  to  the  hospital  March  31,  1871,  suffering 
fearfully  from  cystitis.  It  was  with  the  greatest  difficulty  and  suffer- 
ing that  a  double  catheter  could  be  introduced  for  the  purpose  of 
washing  out  the  bladder,  and  this  finally  became  so  great  that  it  was 
necessary  to  administer  an  anaesthetic  every  other  day,  in  order  to 
effect  it  properly.  As  but  little  improvement  had  taken  place  on 
April  21,  I  made  a  traverse  opening  just  beyond  the  neck  of  the 
bladder,  one  inch  in  length,  and  somewhat  crescentic  in  shape.  This 
was  done  in  consequence  of  the  great  loss  of  tissue,  leaving  insufficient 
room  between  the  cervix  and  neck  of  the  bladder  for  an  incision  in 
the  axis  of  the  vagina.  When  the  finger  was  passed  into  the  bladder, 
its  walls  were  found  much  thickened,  the  mucous  membrane  destroyed 
to  a  great  extent,  and  coated  with  the  most  offensive  phospliatic 
deposit,  which  when  removed  caused  bleeding  from  the  surface  beloAv. 
Her  sufferings  were  so  great,  even  after  the  operation,  that  it  was 
necessary  to  give  her  an  angesthetic  every  other  day  before  washing 
out  the  bladder,  and  often  a  gallon  of  warm  water  was  used  at  a  time 
before  the  deposit  could  be  removed.  A  week  after  the  operation  I 
introduced  a  glass  stud  in  the  opening  to  keep  it  from  closing.  The 
injection  was  continued  daily  until  August  7,  when  the  glass  instru- 
ment was  removed,  as  it  had  begun  to  excoriate  the  posterior  wall  of 
the  vagina.  Her  general  health  improved  rapidly,  and  she  was  free 
from  pain,  except  during  the  time  the  bladder  was  being  syringed  out. 
When  the  finger  was  passed  within  the  bladder  its  surface  was  felt  to 
have  become  smooth,  but  was  still  tender  on  pressure  ;  yet  the  im- 
provement had  been  very  great.  The  injections  were  renew^ed  and 
continued  until  Oct.  1,  half  a  drachm  of  carbolic  acid  beins:  added  to 


736  CYSTITIS. 

each  pint  of  water.  This  had  constituted  all  the  treatment,  except 
that  weak  solutions  of  nitrate  of  silver  were  applied  to  all  denuded 
points,  in  order  to  prevent  the  phosphatic  deposit.  From  some  unex- 
plained cause  a  sudden  relapse  occurred,  beginning  with  a  chill  and 
symptoms  of  pelvic  inflammation,  and  her  condition  became  apparently 
Avorse  than  before  the  operation.  There  was  fever,  and  she  suffered 
from  pain  over  the  hypogastrium,  and  the  urine  became  high  colored 
and  filled  with  urates.  It  was  impossible  to  introduce  the  finger  into 
the  bladder  through  the  opening,  the  edges  of  which  had  long  since 
healed  over,  and  ceased  to  be  sensitive.  Notwithstanding  every  care, 
the  whole  vaginal  surface  became  denuded  of  its  mucous  membrane  as 
a  result  of  the  irritating  character  of  the  urine,  and  coated  with  the 
phosphatic  deposit.  The  labia  inflamed,  and  became  so  sensitive  that 
the  slightest  examination  could  not  be  made,  except  under  the  influence 
of  an  angesthetic.  In  a  few  days  the  urine  was  as  offensive  as  if 
mixed  with  the  contents  of  an  old  pelvic  abscess.  After  awhile  the 
vagina  could  be  syringed  out  several  times  a  day,  and  the  patient  was 
able  to  take  hot  sitz-baths.  Anodynes,  tonics,  and  other  measures 
were  employed  to  meet  indications,  and  ten  drops  of  dilute  nitric  acid 
were  given  three  times  a  day.  As  the  irritation  of  the  vagina  sub- 
sided, its  excoriated  surface  and  the  raw  edges  of  the  fistula  were 
touched  every  other  day  with  a  solution  of  nitrate  of  silver  in  spirits 
of  nitric  ether,  forty  grains  to  the  ounce,  and  after  drying  the  surface 
collodion  was  freely  applied.  She  began  to  improve  rapidly,  and  the 
free  use  of  the  collodion  proved  of  the  greatest  advantage,  not  only  as 
protecting  the  parts  from  the  urine,  but  also  as  a  local  anaesthetic. 

November  II,  she  had  gained  so  rapidly  that  the  finger  could  bs 
introduced  into  the  bladder  without  causing  pain,  and  there  remained 
not  the  slightest  vestige  of  the  cystitis.  I  closed  the  fistula,  using 
eight  sutures,  and  in  denuding  removed  the  surrounding  tissues  freely, 
with  some  doubt  as  to  the  success  of  the  operation  in  consequence  of 
the  cicatricial  character  of  the  edges  which  had  resulted  from  the 
frequent  use  of  the  nitrate  of  silver.  She  was  placed  in  bed,  a  small 
quantity  of  opium  was  ordered  daily,  and  a  light  but  nutritious  diet. 
A  sigmoid  catheter  was  retained  in  the  bladder,  and  only  removed 
night  and  morning  for  the  purpose  of  cleaning  it.  Her  condition  re- 
mained comfortable  until  the  sixth  day,  when  a  small  quantity  of 
urine  began  to  pass  by  the  vagina. 

Nov,  22,  the  sutures  were  removed,  when  it  was  found  that  a  small 
opening  existed  near  the  centre  of  the  line  where  a  suture  had  cut 
out,  due,  it  was  thought,  to  traction  and  the  low  vitality  of  the  parts. 
A  catheter  was  retained  in  the  bladder  for  several  days  longer,  when 
the  quantity  of  urine  lost  diminished  greatly. 

January  20,  1872.  This  patient  continued  under  observation,  and 
was  by  this  time  free  from  all  trouble  of  the  bladder,  was  in  perfect 
health,  and  had  gained  some  twenty  pounds  in  weight.  The  opening 
was  so  small  a  one,  that  when  lying  on  the  back  she  had  retentive 
power.     The  bladder  was  never  entirely  emptied  except  through  the 


CASES.  737 

urethra,  so  that  if  the  cystitis  had  not  been  cured  some  evidence  of  it 
wouUl  have  remained. 

The  sound  coukl  be  passed  into  the  bladder  to  any  point  within  its 
cavity,  without  causiu";  the  slightest  pain  or  irritation.  In  April, 
1872,  one  year  after  the  first  operation,  the  opening  Avas  closed,  and 
she  remained  well  afterwards. 

Case  LIII. — Mrs.  O'B.  aged  35,  was  admitted  to  the  Woman's 
Hospital  Nov.  8,  1867.  INIenstruated  for  the  first  time  at  16.  Mar- 
ried at  17,  and  gave  birth  to  her  only  child  within  a  year  afterwards. 

Four  months  after  marriage  her  husband  died. 

Her  general  health  from  childhood  had  been  delicate.  Three  years 
previous  to  admission  she  had  received  a  severe  fall,  and  from  that 
time  had  never  been  free  from  irritability  of  the  bladder.  This  grad- 
ually increased,  until  at  length  she  had  constant  pain,  and  was  obliged 
to  empty  the  bladder  at  least  evei-y  half  hour  during  the  night  and 
day.  The  urine  was  sometimes  clear,  but  generally  of  a  dark,  fuligi- 
nous hue,  with  often  some  sediment,  and  was  frequently  tinged  with 
blood. 

She  was  found  upon  examination  to  be  suffering  from  cystitis  of 
lono-  standins:,  and  to  have  some  thickening  of  the  walls  of  the  bladder. 
The  uterus  was  retroverted  and  fixed  in  position  irom  some  previous 
attack  of  cellulitis.  The  organ  was  normal  in  size,  but  the  cervix 
was  indurated  and  small,  and  the  os  nearly  closed.  The  microscopic 
examination  indicated  that  the  kidneys  were  yet  in  a  healthy  condi- 
tion. 

An  attempt  was  made  to  correct  the  position  of  the  uterus,  for  the 
cervix  pressed  upward  against  the  base  of  the  bladder,  and  might 
continue  to  prove  a  source  of  irritation.  The  finger,  in  the  rectum 
or  vagina,  was  the  only  means  used  to  lift  up  the  fundus,  for  fear 
of  exciting  the  old  pelvic  inflammation.  This  was  only  partially 
successful.  The  cervix  was  blistered  from  time  to  time  with  acetic 
solution  of  cantharides,  with  the  view  of  lessening  the  induration, 
and  sponge  tents  were  also  carefully  used  for  the  same  purpose,  and 
to  relieve  the  dysmenorrhoea  by  opening  the  os.  Her  general  con- 
dition was  carefully  looked  after.  With  the  view  to  its  effect  on 
the  bladder,  she  was  placed  at  one  time  on  a  mixture  containing  ten 
grains  of  tannin  to  each  dose.  This  frequently  caused  the  urine  to 
become  acid.  When  this  ceased  to  have  the  effect  she  was  placed  on 
a  mixture  containing  benzoic  acid,  the  formula  of  which  was  given 
when  treating  of  vesico-vaginal  fistula  (see  page  619).  Large  doses 
of  old  muriated  tincture  of  iron  were  used,  an  old  preparation  being 
selected,  because,  as  has  been  stated,  it  contains  more  free  acid 
than  the  fresh  preparations.  I  believe  she  at  one  time  readily  took 
a  drachm  three  times  a  day.  An  infusion  of  the  triticum  repens 
was  also  freely  given  for  some  time. 

March  10, 1868.     In  consequence  of  a  slight  exposure  to  cold,  she 
suffered  from  a  severe  attack  of  pelvic  peritonitis,  lost  what  little 
benefit  had  been  gained  by  treatment,  and  was  several  months  con- 
47 


738  CYSTITIS. 

valescing.  At  length,  after  nearly  seven  months'  local  treatment  in 
washing  out  the  bladder  daily,  and  having  exhausted  every  local  and 
constitutional  resource  with  but  little  benefit,  an  operation  was  pro- 
posed. After  fully  explaining  to  the  patient  the  risk  of  life,  in  her 
debilitated  condition,  should  the  operation  again  light  up  the  pelvic 
inflammation,  the  products  of  which  had  not  yet  disappeared,  she 
decided  to  submit  in  spite  of  all  the  dangers,  in  preference  to  remain- 
ino-  in  her  then  sad  condition. 

June  2.  The  patient  was  placed  under  the  influence  of  ether,  and 
with  concurrence  of  Drs.  Alfred  C.  Post,  one  of  the  consulting  sur- 
geons, and  H.  P.  Farnham,  her  former  physician,  the  artificial  opening 
was  made.  The  incision  was  an  inch  and  a  half  in  length,  extending 
from  the  neck  of  the  bladder  nearly  to  the  cervix  uteri.  The  interior 
of  the  bladder  Avas  found  in  the  usual  condition,  with  the  walls  thick- 
ened and  corrugated,  but  with  less  ulceration  of  the  mucous  membrane  ; 
the  latter  condition  being  due  probably  to  the  length  of  time  she  had 
been  under  treatment. 

July  18.  She  was  discharged,  greatly  improved  both  in  her  local 
and  general  condition,  to  return  in  the  autumn.  With  the  greatest 
difficulty  the  fistula  had  been  kept  open,  and  had  become  so  small  as 
scarcely  to  admit  the  finger. 

October  27.  She  was  readmitted  to  the  hospital,  having  been 
under  observation  during  the  summer  as  an  out-door  patient.  Her 
general  health  had  not  improved  to  any  great  extent,  and  she  had 
suffered  greatly  from  the  fistula,  which  had  twice  nearly  closed.  The 
adhesions  were  broken  down  so  as  to  admit  the  finger,  and  at  length 
it  remained  permanently  open,  large  enough  to  admit  a  Ko.  6  catheter, 
through  which  the  urine  escaped.  During  the  winter  the  regular 
treatment  was  kept  up,  with  the  effect  of  much  improving  the  cystitis, 
and  the  Avails  of  the  bladder  became  softer.  Much  thickening,  hoAV- 
ever,  and  induration  at  the  neck  of  the  bladder  remained,  Avith  tender- 
ness in  the  urethra,  making  it  unbearable  to  introduce  a  catheter  into 
the  canal. 

June  4,1869.  For  several  months  previous  a  solution  of  morphine, 
containing  eight  grains  to  the  ounce,  had  been  throAvn  into  the  bladder, 
after  Avasbing  it  out  Avith  Avarm  Avater.  As  she  lay  on  her  back,  it 
was  thrown  somcAvhat  as  a  spray  through  the  fistula,  so  as  to  wet  the 
upper  portion  of  the  bladder,  out  of  reach  of  the  urine,  and  the  excess 
floAved  off  below.  This  plan  Avas  folloAved  Avith  great  benefit,  so  that 
there  was  decidedly  less  tenderness  on  pressure  in  every  portion  of 
the  bladder,  but  she  continued  to  complain  Avhenever  a  catheter  Avas 
introduced. 

^th.  A  relapse  occurred,  apparently  without  cause,  a  constant 
desire  to  empty  the  bladder  coming  on,  although  the  urine  all  escaped 
freely  by  the  vagina.  Dr.  Robert  NcAvman  kindly  examined  the 
bladder  for  me  Avith  the  endoscope.  Its  raucous  membrane  Avas  found 
to  be  in  a  normal  condition.  As  the  instrument  Avas  sloAvly  introduced 
into  the  urethra,  every  portion  of  the  canal  Avas  carefully  inspected. 
At  first,  nothing  could  be  found,  but  at  length  a  minute  granular  point 


CASES.  739 

was  detected  on  the  left  side,  about  an  inch  from  the  orifice,  intensely 
red,  and  painful  to  the  touch.  Churchill's  solution  of  iodine  Avas 
applied,  which  gave  much  pain,  lasting  eight  hours. 

lC)f//.  The  patient  was  again  examined,  and  it  was  found  that 
no  improvement  liad  taken  place.  The  iodine  application  was  repeated, 
with  less  pain  than  after  the  previous  examination. 

21st.  A  weak  solution  of  nitrate  of  silver  was  applied  to  the 
ulcerated  points,  and  repeated  on  the  24th  and  28th  inst.  The  patient 
complained  a  great  deal  of  pain  after  each  application,  but  the  surface 
gradually  healed.  She  remained  in  the  hospital  during  the  summer, 
without  further  treatment  than  the  injection  of  water  into  the  bladder. 
In  December  the  fistula  was  closed,  but  on  removing  the  sutures  the 
edges  separated  immediately,  no  union  having  taken  place  in  conse- 
quence of  the  cicatricial  character  of  the  edges,  resulting  from  the 
frequent  use  of  the  nitrate  of  silver.  As  her  general  health  was  still 
poor,  the  fistula  was  not  again  closed  until  May  31,1870.  The  vagi- 
nal tissue  around  the  edges  of  the  opening  were  freely  removed  with 
a  pair  of  scissors,  and  the  surfaces  secured  by  seven  sutures.  June 
9,  the  sutures  were  removed,  and  the  edges  found  firmly  united.  She 
was  discharged  cured  July  18, 1870,  having  been  two  years  and  some 
eight  months  under  daily  observation  and  treatment.  After  her  dis- 
charge her  general  health  improved,  and  she  had  no  further  trouble 
with  her  bladder.  She  continued  to  improve,  and  was  in  good  health 
when  she  returned  to  her  friends  in  Ireland  two  years  later. 

By  so  full  a  history,  as  of  the  two  cases  just  given,  a  general 
idea  of  the  treatment  can  be  obtained,  and  the  reader  would  gain 
scarcely  more  knowledge,  were  a  number  of  other  cases  added.  But 
in  regard  to  the  condition  of  the  kidneys,  the  following  case,  and  one 
to  be  given  when  treating  of  laceration  of  the  urethra,  will  elucidate 
the  post-mortem  appearance,  when  death  occurred  after  the  adminis- 
tration of  ether. 

Case  LIV. — Mrs.  S.  admitted  to  the  Woman's  Hospital  June  22, 
1868,  aged  39.  Had  married  at  21.  Sterile.  Shortly  after  mar- 
riage had  an  attack  of  cellulitis  from  putting  her  feet  in  cold  Avater  to 
check  her  period.  Four  years  after  first  attack,  had  a  recurrence 
which  terminated  in  pelvic  abscess,  which  after  several  months  opened 
into  the  vagina.  About  15  months  previous  to  admission  the  urine 
began  to  escape  into  the  vagina,  with  partial  relief  to  the  cystitis 
afterwards.  June  23,  ether  was  administered  for  the  purpose  of  en- 
larging the  sinus  to  admit  of  the  free  escape  of  urine  from  the  bladder. 
Through  the  vagina  could  be  felt  the  remains  of  an  old  abscess, 
running  from  the  left  broad  ligament  down  between  the  uterus  and 
the  bladder.  The  bladder  was  also  felt  contracted  and  hard.  She 
was  placed  on  the  left  side,  and  Sims's  speculum  introduced.  The 
mouth  of  the  sinus  leading  into  the  uterus   was  found  in  front  of  the 


740  STONE    IX    THE    BLADDER    AND    URETERS. 

uterus.  The  opening  was  of  a  sufficient  size  to  admit  a  large-sized 
sound  into  the  bladder,  but  did  not  allow  of  a  free  escape  of  unne. 
A  certain  quantity  would  collect,  and  then  escape  all  at  once  as  if 
driven  out  by  contraction  of  the  bladder.  The  general  condition  was 
very  poor,  but  with  the  hope  of  relieving  the  irritation  of  the  bladder, 
and  there  being  no  prospect  of  relief  otherwise,  the  opening  was  en- 
larged about  half  an  inch.  This  was  just  sufficient  to  admit  the  fin- 
ger into  the  bladder,  which  Avas  found  contracted  and  thickened,  and 
having  lost  a  large  portion  of  its  mucous  membrane  from  ulceration. 
Death  resulted  from  uramia,  forty-eight  hours  after  the  operation. 
At  the  post-mortem  examination,  it  was  found  that  for  a  long  time  she 
had  suffered  from  tubercular  peritonitis.  The  sac  of  the  old  abscess 
was  found  as  described.  The  left  kidney  was  enlarged  and  dilated. 
The  cortical  portion  was  nearly  gone,  and  the  tissues  apparently  in  a 
state  of  fatty  degeneration. 

The  pelvis  of  the  kidney  was  dilated  enough  to  contain  some  three 
ounces  of  fluid,  and  the  ureter  large  enough  to  admit  two  fingers. 
The  right  kidney  was  destroyed,  and  had  done  no  work  for  years.  It 
was  enlarged,  but  nothing  was  left  but  the  capsule  containing  half  a 
pint  or  more  of  a  deposit  having  the  appearance  and  consistency  of 
white  lead.  The  liver  was  enlarged  and  fatty,  and  there  was  an 
abnormal  amount  of  fluid  in  the  pericardium. 

Dr.  Francis  Delafield  made  a  microscopic  examination  of  the  two 
kidneys.  The  right  one  was  the  seat  of  very  extensive  tubercular 
deposit,  the  tubercles  having  undergone  cheesy  degeneration.  Scarcely 
a  trace  of  the  kidney  structure  remained.  The  pelvis  of  the  other 
kidney  was  dilated.  The  epithelium  of  the  calyces  and  convoluted 
tubes  were  in  a  state  of  fatty  degeneration,  and  some  of  the  Malpighian 
bodies  were  contracted  and  hard. 

Stone  in  the  Bladder  and  Ureters. — It  is  a  common  belief  that 
residence  in  a  limestone  country,  favors  the  development  of  stone  in 
the  bladder. 

Under  all  circumstances,  however,  the  formation  of  stone  in  the 
bladder  of  the  female  is  less  frequent  than  in  the  male.  This  is  due 
to  the  fact  that  the  female  urethra  is  short,  and  of  large  calibre,  and 
facilitates  the  easy  passage  of  sabulous  particles. 

In  this  portion  of  the  United  States,  stone  is  exceedingly  rare 
except  as  an  accompaniment  of  cystitis ;  or  after  an  operation  for 
closing  a  vesico-vaginal  fistula  ;  or  as  a  consequence  of  the  introduc- 
tion of  some  foreign  body  into  the  bladder,  by  the  woman  herself. 

The  character  of  the  stone  is  therefore  almost  always  phosphatic, 
being  the  result  of  some  irritating  cause,  while  the  uric  acid  forma- 
tion so  commonly  found  in  the  male,  and  depending  on  a  constitutional 
condition,  are  rarely  met  with  among  women.  It  is  likely  that  the 
uric  acid  deposit  is  as  frequent  with  women  as  with  the  men,  but  it  is 


CAUSES    OF    STONE.  741 

washed  out  before  it  has  time  to  effect  a  lodgment.  The  develop- 
ment of  phosphatic  calculi,  however,  is  rapid,  as  the  phosphates 
readily  precipitate  upon  any  foreign  body  that  may  be  present,  form- 
ing incrustations  which  are  not  easily  dislodged. 

I  have  seen  two  instances  of  stone  in  the  bladder  due  to  spinal 
injury  resulting  in  loss  of  motion  and  sensation. 

In  1868  I  was  consulted  in  the  case  of  a  lady  from  Norfolk,  Va., 
who  was  suffering  with  paralysis  of  the  lower  limbs,  from  a  fall.  Four 
months  after  the  fall  urine  began  to  escape  by  the  vagina,  and  in  a 
few  days  a  sufficient  number  of  calculi  were  passed  to  fill  a  large-sized 
tumbler.  I  found  on  examination  that  the  whole  base  of  the  bladder 
had  been  lost,  as  well  as  the  urethra  and  the  sub-pubic  tissue  up  to 
the  periosteum ;  the  vagina  was  almost  occluded.  The  urine  had 
been  allowed  to  accumulate  in  the  bladder  after  the  injury,  as  she 
had  doubtless  lost  all  sensation  in  the  parts,  and  the  bladder  was 
afterwards  never  thoroughly  emptied.  The  urine  becoming  highly 
phosphatic  gave  rise  to  the  formation  of  calculi,  which,  by  the  pres- 
sure upon  the  vesico-vaginal  septum,  produced  a  slough  on  account  of 
the  impaired  vitality  of  the  parts.  No  attempt  was  made  for  her 
relief,  as  the  paralysis  had  not  yet  disappeared,  and  even  had  it  been 
possible  to  close  the  opening,  doubtless  sloughing  would  have  again 
followed  in  a  few  weeks.  I  was  never  able  to  learn  her  subsequent 
history. 

The  other  patient  gradually  recovered  sensation  and  motion,  and 
the  stone  was  recognized  and  removed. 

In  cystitis  calculi  frequently  form  in  some  pouch  where  the  urine 
is  being  retained  until  it  becomes  decomposed  and  phosphatic. 

In  the  greater  proportion  of  the  cases  which  have  passed  under  my 
observation  the  calculi  have  formed  within  one  or  two  years  after  a 
vesico-vaginal  fistula  had  been  closed,  and  generally  when  the  opera- 
tion had  not  been  performed  by  myself.  The  formation  has  more 
frequently  followed  some  operation  about  the  neck  of  the  uterus,  and 
generally  when  laceration  had  occurred  through  the  anterior  lip  into 
the  base  of  the  bladder.  I  have  in  several  instances  found  the  nucleus 
to  be  a  small  portion  of  wire  which  had  dropped  into  the  bladder  as 
the  end  of  some  suture  had  been  clipped.  But  as  a  rule  I  believe  the 
nucleus  is  furnished  by  some  denuded  surface  which  had  been  turned 
into  the  bladder,  or  left  there  through  a  careless  adjusting  of  the  edges 
of  the  fistula.  Dr.  Henry  F.  Campbell,  of  Augusta,  Ga.,  has  offered 
a  different  explanation  of  the  origin  of  calculi  after  the  operation  for 


742        STONE  IN  THE  BLADDER  AND  URETERS. 

vesico-vaginal  fistula:^  "Reasoning,  then,  from  my  own  case,  and 
from  others  in  which  calculi  of  considerable  size  have  been  found 
to  exist  in  the  bladder  shortly  after  closing  of  fistulge  by  operation  I 
conclude,  1st,  that  in  such  cases  the  stone  exists  previous  to  the  fis- 
tula, perhaps  causing  the  slough  during  the  labor  in  which  it  occurs  ; 
2d,  that,  like  the  present  stone,  they  are  grasped  by  the  empty  blad- 
der, and  remain  imbedded  during  the  entire  period  of  the  existence  of 
the  fistula  ;  and,  3d,  that  when  the  fistula  had  been  closed  by  opera- 
tion, and  the  collection  of  urine  in  the  bladder  becomes  again  possible, 
the  consequent  distension  releases  the  stone  ;  the  calculus  is  not, 
therefore,  in  pi'ocess  of  formation  in  the  bladder  at  that  time,  but  is 
only  discovered  after  the  case  of  the  fistula." 

This  explanation  is  original,  and  I  have  no  doubt  is  a  correct  one 
for  a  large  number  of  cases.  I  can  recall  several  instances  in  my 
own  experience  where  I  was  unable  to  offer  to  myself  any  explanation 
for  so  rapid  a  development  of  stone  within  a  few  weeks  after  closing 
the  fistula.  But,  on  the  other  hand,  I  have  known  of  several  cases 
where  the  loss  of  tissue  had  been  too  great,  and  too  large  a  portion  of 
the  bladder  had  been  constantly  inverted  for  a  stone  to  have  had  any 
lodgment.  I  acknowledge  the  importance  of  Dr.  Campbell's  explana- 
tion, and  the  consequent  necessity  for  passing  the  finger  into  the  inte- 
rior of  every  bladder  before  closing  it.  But  I  am  equally  certain  that 
an  undenuded  surface  left  in  the  bladder  will  furnish  a  starting-point, 
and  a  stone  may  be  developed  within  a  short  time  after  closing  the 
fistula. 

The  symptoms  of  stone  resemble  closely  those  of  cystitis,  and, 
unless  a  steel  sound  be  passed  into  the  bladder,  the  differentiation  will 
not  be  easy.  This  is  best  done  while  the  patient  lies  on  the  back, 
with  her  limbs  flexed  on  the  abdomen,  and  held  by  an  assistant  on 
each  side.  The  administration  of  ether  is  generally  necessary,  and 
it  is  well  to  moderately  distend  the  bladder  with  tepid  water  before 
attempting  the  examination. 

There  are  two  methods  by  which  a  stone  may  be  removed  from  the 
bladder :  through  the  urethra  or  through  an  opening  made  in  the  base 
of  the  bladder  from  the  vagina.  The  removal  by  the  urethra  is  the 
oldest  method.  .  When  the  stone  is  soft  and  of  a  moderate  size  it  may 
be  readily  crushed  by  a  lithotrite,  and,  if  it  be  thoroughly  broken  up, 
the  debris  will  rapidly  pass  through  the  urethra.     As  a  woman,  in 

1  Origin  and  History  of  Calculi  found  in  the  Bladder,  after  the  Cure  of  Vesico- 
vaginal Fistula  by  Operation.    American  Gynecological  Transactions,  vol.  i.  1876. 


LITIIOTRITY.  743 

comparison  with  a  man,  is  little  liable  to  Inflammation,  the  stone 
should  be  repeatedly  and  thoroughly  crushed,  and  it  should  all  be 
accomplished  at  a  single  sitting.  But  this  should  not  be  under- 
taken unless  the  operator  has  acquired  a  reasonable  amount  of  dex- 
terity. The  chief  danger  is  in  wounding  or  lacerating  the  lining 
membrane  and  neck  of  the  bladder.  The  first  can  be  avoided,  but  the 
second  cannot  ahvays  be  guarded  against,  and  is  really  the  chief 
danger  and  objection  in  this  mode  of  operating.  The  bladder  should 
be  filled  with  water,  and  on  picking  up  the  stone  the  precaution  should 
always  be  taken  to  turn  the  instrument  to  one  side  and  then  to  the 
other  and  gently  draw  it  forward,  that  we  may  be  certain  that  no 
portion  of  the  viscus  is  included  within  the  grasp  of  the  instrument. 

After  the  stone  has  been  broken  up  it  is  of  the  greatest  importance 
to  remove  the  fragments  as  soon  as  possible,  since  the  presence  of 
these,  it  is  now  well  recognized,  will  usually  cause  more  irritation  than 
is  likely  to  result  from  any  ordinary  amount  of  manipulation.  By 
injecting  a  quantity  of  water,  through  a  large-sized  double  catheter, 
the  ddbris  can  generally  be  washed  out,  but  the  procedure  is  not  al- 
ways satisfactory,  and  I  have  preferred  to  remove  the  stone  entire 
through  an  incision  from  the  vagina. 

Dr.  Henry  J.  Bigelow,'  of  Boston,  has  devised  an  excellent  method 
for  crushinsr  a  stone  in  the  male  bladder,  and  for  removing  the  frag- 
ments,  Avhich  it  appears  is  even  yet  more  applicable  in  the  female. 
His  evac\iating  apparatus  consists  of  an  elastic  bulb,  with  a  glass  tube 
attached  for  receiving  the  fragments  of  stone.  The  bulb  communi- 
cates by  means  of  rubber  tubing  with  the  canula,  which  is  introduced 
into  the  bladder.  It  requires  some  little  skill  to  carry  the  fenestra  of 
the  instrument  to  the  most  dependent  points,  and  to  keep  it  free  from 
being  stopped  up  by  the  walls  of  the  bladder.  The  bulb  is  first  filled 
with  tepid  water,  and  then  emptied  into  the  bladder  by  compressing 
it  slowly.  It  is  next  allowed  to  expand,  and,  in  doing  so,  the  water 
returns  into  it  from  the  bladder,  bi'inging  with  it  a  greater  or  less 
quantity  of  the  crushed  fragments,  which  quickly  subside  into  the  glass 
tube,  and  are  not  thrown  back  into  the  bladder  when  the  bulb  is  again 
compressed.  Any  larger  pieces  that  remain  must  in  turn  be  crushed, 
until  all  have  been  broken  down  to  a  size  which  will  admit  of  their 
passage  through  the  evacuating  canula. 

Dr.  Bigelow's  paper  is  of  the  utmost  practical  importance  in  re- 

'  Lithotrity  by  a  Single  Operation.  Am.  Journ.  of  the  Med.  Sciences,  Phila., 
Jan.  1878. 


744        STOXE  IX  THE  BLADDER  AXD  UEETERS. 

futing  the  long-accepted  doctrine  that  the  crushing  of  stone  -with 
safety  is  a  process  to  be  extended  over  an  indefinite  period.  It  is 
shown  IjY  him  that  this  method  compares  most  favorably  Avith  the  best 
which  have  been  demed  for  removing  stone. 

When  the  coats  of  the  bladder  have  become  thickened,  and  marked 
cystitis  exists,  the  proper  course  is  to  extract  the  stone  through  an 
artificial  opening  in  the  vesico-vaginal  septum. 

A  stone  can,  by  this  means,  be  safely  removed  by  one  who  may  not 
possess  the  dexterity  to  crush  it  properly.  It  is  the  operation  liCLf 
excellence  when  the  bladder  has  become  so  diseased  that  absolute  rest 
is  required,  and  rest  is  to  be  obtained  only  by  allowing  the  urine  to 
escape  as  rapidly  as  it  enters  the  bladder. 

I  do  not  know  to  whom  we  are  indebted  for  this  procedure,  but  the 
success  attending  the  closure  of  vesico-vaginal  fistulse  renders  it  prac- 
ticable. The  operation  does  not  differ  essentially  from  that  described 
for  the  relief  of  cystitis  by  opening  the  base  of  the  bladder. 

After  the  stone  has  been  removed  the  patient  should  be  turned  on 
the  back,  placed  over  a  bed-pan,  the  nozzle  of  the  syringe  introduced 
through  the  urethra,  and  the  bladder  thoroughly  washed  out,  while 
the  sides  of  the  fistula  are  kept  apart  by  the  index  finger  introduced 
into  the  vagina.  After  removal  of  the  stone,  the  opening  thus  made 
is  closed  in  the  same  manner  as  for  vesico-vaginal  fistula  generally, 
and  it  should  be  closed  immediately,  unless  the  mucous  membrane  is 
found  to  be  in  a  diseased  condition.  In  this  event,  the  case  must  be 
treated  as  if  it  were  one  of  cystitis,  and  the  opening  left  for  the  free 
escape  of  urine  until  the  parts,  by  rest,  gradually  recover  their  tone. 

Removal  of  Stone  from  the  Ureters. — Calculi  are  freijuently  formed 
in  the  pelvis  of  the  kidneys,  and,  Avhile  yet  small,  pass  through  the 
ureters  into  the  bladder,  there  to  furnish  nuclei  for  larger  accretions, 
or,  happily,  to  escape  by  the  urethra. 

I  have  met  with  three  instances  where  the  stone  had  been  unable 
to  pass  into  the  bladder,  and  had  remained  at  the  mouth  of  the  ureter, 
acting  as  a  ball  valve.  This  condition  leads  to  more  or  less  dilata- 
tion of  the  ureter,  and  causes  backache,  irritability  of  the  bladder,  a 
sense  of  weight  about  the  pelvis,  and  other  symptoms,  which,  unfor- 
tunately, are  in  nowise  pathognomonic  of  the  condition.  The  symp- 
toms are  all  well  marked  as  to  the  existence  of  a  stone  in  the  bladder, 
but  become  obscure  when  one  is  not  found.  To  add  to  the  difficulty, 
the  steel  sound  Avill  sometimes  pass  over  the  stone,  furnishing  the 
characteristic  sensation,  but  after  a  number  of  careful  examinations 
it  may  fail  to  elicit  any  further  information.     In  two  instances  I 


EEMOVAL    OF    STONE    FROM    THE    URETERS.  745 

had  detected  the  presence  of  stone,  and  had  invited  several  gentle- 
men to  witness  rac  opei'ate  for  its  removal,  but,  to  my  mortification, 
the  stone  could  not  be  felt  again,  and  the  operation  was  postponed. 
In  one  of  these  cases  I  afterwards  opened  the  bladder,  seeking  for  a 
solution  of  the  mystery,  and  detected  with  my  finger  the  stone  in  the 
mouth  of  the  ureter.  I  then  passed  the  instrument,  which  has  been 
described  as  the  curette  forceps,  alongside  of  my  finger  into  the 
ureter,  and  withdrew  the  stone  with  comparatively  little  difficulty. 

In  a  subsequent  case  having  always  felt  the  click  of  the  steel  sound 
at  the  same  point,  I  was  led  to  suspect  that  the  stone  was  in  the  ure- 
ter, and  by  making  slight  backward  pressure  with  a  large  sound  in  the 
bladder,  I  was  able  to  feel  it  with  my  finger  either  in  the  vagina  or 
rectum. 

As  the  patient  lay  on  the  side,  with  a  speculum  introduced,  I  cut 
down  on  the  stone  with  a  pair  of  scissors  Avhile  an  assistant  kept  the 
parts  prominent  by  pressing  backward  and  upward  with  a  sound  in 
the  bladder. 

As  soon  as  I  reached  the  stone,  I  enlarged  the  opening  forward, 
towards  the  neck  of  the  bladder,  this  being  the  only  safe  direction  to 
avoid  entering  the  peritoneal  cavity.  After  considerable  difficulty  I 
succeeded  in  getting  hold  of  the  stone,  and  in  withdrawing  it  without 
having  entered  the  bladder  or  peritoneal  cavity. 

This  stone  is  in  the  collection  of  Dr.  Edward  L.  Keyes  of  this  city 
who  has  furnished  me  with  the  following  description.  "The  general 
shape  and  size  is  like  a  portion  of  the  little  finger,  the  surface  being 
smoothly  bossed.  Its  long  diameter  measured  1|  inch,  after  a  small 
portion  had  been  broken  off  and  lost ;  the  short  diameter  |  inch.  The 
greatest  circumference  4|  inches  ;  the  lesser  one  1|  inch.  The  weight 
was  98  grains,  twelve  years  after  its  removal.  Its  composition  Avas 
mainly  carbonate,  with  some  phosphate  of  lime,  a  trace  of  amorphous 
urate,  and  a  little  organic  matter." 

I  closed  the  opening  with  interrupted  sutures,  and  was  particularly 
careful  to  see  that  their  points  of  exit  and  entrance  were  along  the 
external  surface  of  the  ureter,  so  that  the  line  approximated  with  the 
greatest  accuracy.     The  case  made  a  good  recovery. 


746  DISEASES    OF    THE    OVARIES, 


CHAPTER  XXXVI. 

DISEASES  OF  THE  OVARIES. 
Ooplioritis — Enlargement — Treatment — Battey"s  operation. 

Primary  interstitial  inflammation,  or  (according  to  Kiwisch^)  in- 
flammation of  the  ovai'ian  stroma,  occurs  very  seldom  in  the  non-puer- 
peral state,  especially  if  we  exclude  slight  oedemas  and  hypersemias, 
which  are  frequently  developed  in  the  pelvic  organs  during  menstrual 
congestions,  and  other  determinations  of  blood. 

Schroedei^  states :  "  Two  forms  of  oophoritis  are  to  be  distinguished: 
the  parenchymatous,  or  follicular,  in  which  the  structures  proper  of 
the  gland,  the  Graafian  follicles,  are  inflamed,  and  the  interstitial,  in 
which  the  connective  tissue  stroma  is  inflamed.  Inflammation  of  the 
glandular  part  of  the  Graafian  follicles  is,  according  to  the  investiga- 
tions of  Slavjansky,  very  frequent."  Scanzoni  and  others  designate 
a  third  form  due  to  "  inflammation  of  the  peritoneal  covering  of  the 
ovary,"  but  as  recent  observers  have  been  able  to  demonstrate  the 
fact  that  the  ovary  is  not  covered  by  the  peritoneum,  this  form  cannot 
be  accepted  without  further  explanation.  The  surface  of  the  ovary 
undoubtedly  becomes  inflamed,  but  this  is  due  to  its  close  connection 
with  the  peritoneum,  so  that  any  inflammation  of  this  membrane  in  the 
neighborhood  of  the  ovary  must  involve  that  organ.  This  is  so  com- 
mon that  we  believe  the  ovaries  suff'er  far  more  from  peritonitis  or 
cellulitis  in  their  vicinity  than  from  disease  originating  within,  or  con- 
fined to,  their  own  structure. 

Scanzoni'  met  with  only  a  single  case  of  non-puerperal  acute 
ovaritis,  where,  in  consequence  of  death  from  pneumonia,  he  was  en- 
able to  study  the  exact  pathological  changes.  After  describing  the 
post-mortem  condition  he  says :  "  The  pathological  alterations  which 
we  have  met  with  in  this  ovary  correspond  perfectly  to  the  description 

'  Diseases  of  the  Ovaries,  etc.,  translated  by  John  Clay,  London  MDCCCLX. 
p.  65. 

2  Ziemssen's  Cyclopaedia  of  the  Practice  of  Medicine,  vol.  x.  N.  Y.  1S75,  p.  351. 

3  N.  y.  edition,  p.  396. 


CAUSES    OF    OVARIAN    DISEASE.  747 

which  some  autliors  have  given  of  acute  ovaritis ;  considerahle  in- 
crease in  the  size  of  the  organ,  notable  hypercemia,  traces  of  ctt'usion 
in  the  vesicles,  purulent  foci  in  the  parenchyma,  and  fibrinous  exuda- 
tion under  the  pei'itoneal  envelope  of  the  organ.  After  what  precedes, 
it  may  be  seen  that  in  this  case  we  had  a  combination  of  the  three 
forms  of  ovaritis,  which  confirms  our  assertion  on  the  subject  of  the 
rarity  of  its  existence  in  an  isolated  form." 

As  rare  as  ovaritis  is  in  the  non-puerperal  state,  the  opportunity  is 
afforded  still  less  seldom  to  study  its  post-mortem  appearances.  When 
the  whole  ovary  becomes  enveloped  in  a  mass  of  lymph,  as  in  this 
case,  the  vesicles  themselves  must  become  inflamed,  since  they  are 
unable  to  discharge  their  contents.  We  have  here,  doubtless,  a  clue 
to  the  cause  of  many  cases  of  sterility,  because  such  a  condition  must 
prevent  the  escape  of  the  ova  from  the  Graafian  vesicles,  and  induce 
atrophy  of  the  ovary.  The  severe  character  of  the  pain  so  commonly 
experienced  may  be  due  to  pressure,  as  in  the  case  of  hematocele, 
where  the  limited  space,  Avhich  has  been  completely  closed  in  by  the 
inflammatory  process,  becomes  distended  by  continued  effusion  of 
blood. 

The  ovaries  are  supplied  with  nerves  from  the  renal  plexus,  but  so 
scantily  that  in  the  absence  of  inflammation,  a  doubt  may  arise  as  to 
the  pain  which  is  so  frequently  experienced  in  their  neighborhood 
being  due  to  "  ovarian  irritation,"  or  whether  even  it  has  any  direct 
connection  with  the  ovaries.  A  woman  seldom  suffers  from  "  ovarian 
neuralgia"  without  at  the  same  time  givino;  evidence  of  uterine  dis- 
ease,  but  it  is  not  always  easy  to  place  these  two  phenomena  in  their 
proper  relation  of  cause  and  effect.  We  may  often  be  able  to  attribute 
the  diseased  condition  in  both  organs  to  a  common  cause,  extrinsic  to 
both.  Any  obstruction  to  the  circulation  in  the  pelvic  connective 
tissue,  if  due  to  nothing  more  than  a  general  lack  of  tone,  tends  to 
increase  the  venous  circulation  in  both  ovary  and  uterus.  The  re- 
mains of  an  old  cellulitis  have  the  same  effect,  and  may  so  obstruct 
the  circulation  as  to  establish  an  erosion  on  the  cervix,  the  result  of 
nature's  efforts  to  relieve  the  congestion  by  an  increase  of  secretion. 

Much  damage  is  done  at  times  by  inflammation  due  to  childbirth, 
the  subsequent  contraction  and  pressure  producing  disturbance  of  the 
nervous  system,  and  of  menstruation,  and  even  sterility.  But  we 
possess  no  positive  means  of  recognizing  these  pathological  changes 
during  life,  or,  if  recognizing  them,  to  remedy  the  difficulty.  It  is  of 
no  practical  value  to  make  a  distinction  as  to  any  special  form  of 
oophoritis,  and  the  fact  already  stated,  may  be  remembered  that  the 


748  DISEASES    OF    THE    OVARIES. 

ovary  itself  is  seldom  the  seat  of  inflammation,  except  as  a  result  of 
childbirth. 

Inflammation  of  the  ovary,  however,  sometimes  occurs  after  surgical 
operations  on  the  uterus,  or  after  a  sudden  suppression  of  the  men- 
strual flow.  But  it  usually  exists  coincident  with  cellulitis  and  peri- 
tonitis, and  presents  no  distinct  symptoms  to  indicate  that  the  ovary  is 
involved.  As  a  rule,  the  symptoms  of  a  severe  peritonitis  will  so 
mask  every  other  condition,  that  the  extent  of  injury  to  the  ovary  is 
only  to  be  estimated  later  from  any  damage  to  it  which  may  become 
apparent.  It  may  only  have  become  "  scorched"  in  the  general  con- 
flagration, and  its  function  may  be  afterwards  restored  by  a  reparative 
process,  that  is,  so  far  as  relates  to  the  proper  performance  of  ovula- 
tion ;  but  should  adhesions  form,  sterility  would,  in  all  probability, 
result  from  the  ovum  being  obstructed  in  its  passage  to  the  uterine 
cavity. 

But  whatever  may  be  the  exciting  cause  of  the  oophoritis,  its  course 
varies  but  little.  If  the  inflammation  has  extended  to  the  deeper 
tissues,  and  recovery  does  not  take  place  by  resolution,  the  follicles  be- 
come involved  one  after  the  other,  but  by  so  slow  a  progress  that  the 
condition  maybe  termed  a  chronic  inflammation,  and  recurrent  attacks 
of  local  peritonitis  are  frequent.  At  length  the  inflammation  brings 
about  contraction  of  the  follicles,  and,  bands  forming  on  the  surface, 
a  condition  of  atrophy  is  produced,  compared  by  difierent  writers  to 
cirrhosis  of  the  liver. 

Abscesses  sometimes  form  in  the  ovary,  but,  as  a  rule,  the  local 
condition  is  practically  a  pelvic  cellulitis,  or  peritonitis,  as  far  as  con- 
cerns the  symptoms,  progress,  and  termination.  The  escape  of  the 
pus  takes  place  through  the  pelvic  cellular  tissue  and  peritoneum  most 
frequently  into  the  peritoneal  cavity,  or  into  the  intestines ;  but  it 
may  pass  into  the  rectum,  vagina,  bladder,  or  along  the  course  of  the 
psoas  muscles.  An  abscess  in  the  ovary  would  present  the  same 
general  symptoms  as  a  pelvic  abscess,  but  a  digital  examination  per 
rectum  Avould  disclose  the  altered  shape  of  the  ovary,  and  a  greater 
mobility  of  the  mass  than  is  ever  presented  in  cellulitis.  With  an 
ovarian  abscess  the  life  of  a  woman  is  certainly  in  greater  jeopardy 
than  it  would  be  in  inflammation  of  the  cellular  tissue  of  the  pelvis, 
since  the  probability  is  much  greater  that  rupture  would  occur  into 
the  peritoneal  cavity  before  adhesions  had  taken  place. 

Kiwisch,  p.  94,  states:  "Thus  we  have  seen  patients  who  have 
carried  abscesses  of  considerable  size  in  the  pelvis  for  years,  and  who 


ABSCESS  OF  THE  OVARY.  749 

have  attended,  in  comparative  health,  to  their  domestic  duties."     I 
have  seen  but  one  instance  of  this  kind. 

CaseLV. — Feb.  13, 1872,  Mrs.  D.,aged  48,  came  under  my  care, 
after  a  consultation  with  Dr.  Noyes,  who  had  been  treating  her  for 
eye  trouble,  and  had' suspected  a  possible  reflex  irritation  from  some 
uterine  disease.  She  gave  the  following  history :  Menstruation  ap- 
peared for  the  first  time  at  15  ;  she  became  regular  at  once,  the  flow 
lasting  a  Aveek  without  pain,  and  she  was  in  excellent  health  when 
married  at  20  years  of  age.  She  gave  birth  to  six  children,  at  full 
term,  by  natural  labor,  and  had  miscarried  twice.  The  last  child  was 
then  eight  years  old,  and  the  last  pregnancy  terminated  in  miscarriage, 
at  four  months,  about  five  years  previous  to  consulting  me.  She  stated 
that  it  had  been  necessary  to  employ  instruments  to  remove  the  foetus, 
and  she  suffered  from  hemorrhage.  She  had  a  long  convalescence, 
and  never  after wai^ds  entirely  regained  her  previous  good  health. 
Menstruation  after  this  miscarriage  became  more  free,  lasting  from 
ten  to  twelve  days,  frequently  amounting  in  quantity  to  a  hemorrhage, 
and  often  returning  in  the  intervals  between  the  periods.  She  had 
gradually  become  weaker,  and  unable  to  exercise  or  stand  for  any 
length  of  time  without  aggravating  a  pain  on  the  left  side,  from  which 
she  was  seldom  free. 

The  uterus  was  four  inches  deep,  and  anteverted.  A  number  of 
granulations  in  the  uterine  canal  could  be  felt  with  the  probe,  and  on 
withdrawing  the  instrument  the  discharge  of  blood  was  quite  free. 
An  unusually  deep  fissure  existed  through  the  posterior  lip,  which 
had  extended  partially  into  the  bottom  of  Douglas's  cul-de-sac,  and 
healed,  but  yet  remained  patulous  enough  to  allow  a  finger  to  be  in- 
ti'oduced  nearly  to  the  internal  os.  A  mass,  about  the  size  of  a  large 
hen's  egg,  w^as  felt  on  the  left  side.  This  could  not  be  well  defined 
from  the  vagina,  but  as  felt  from  the  rectum  it  was  found  to  be  uniform 
in  shape,  and  was  supposed  to  have  been  the  remains  of  an  old  cellu- 
litis involving  the  ovary.  She  was  very  anaemic,  and  a  functional 
murmur  was  audible  over  the  region  of  the  heart,  and  the  vessels  of 
the  neck. 

Feb.  16.  She  entered  my  private  hospital,  flowing  very  freely. 
She  was  kept  in  bed,  and  an  application  of  impure  carbolic  acid  was 
made  to  the  fundus  daily  by  means  of  the  application,  followed  by  a 
vaginal  tampon.     By  Feb.  21st,  the  hemorrhage  was  arrested. 

23c?.  A  sponge  tent  was  introduced,  which  dilated  the  canal  fully, 
and  after  removing  a  large  quantity  of  granulations,  with  the  proper 
forceps,  I  applied  equal  parts  of  carbolic  acid  and  glycerine  freely 
throughout  the  canal.  This  had  the  eff"ect  of  arresting  the  flow  of 
blood  for  a  month.  At  the  end  of  that  time,  however,  there  came  on 
a  watery  discharge,  which  it  was  thought  advisable  to  stop,  if  possible, 
on  account  of  the  extremely  anaemic  condition  of  the  patient. 

March  25.  The  canal  was  again  partially  dilated,  to  facilitate  the 
application  of  the  carbolic  acid.  She  had  no  further  local  treatment, 
and  suffered  no  inconvenience  afterwards,  and  there  was  a  decided 


750  DISEASES    OF    THE    OVARIES. 

improvement  in  both  her  appearance  and  strength.  This  was  her 
condition  on  retiring  to  bed. 

oOth.  The  weather  was  mild,  and  the  temperature  of  her  room 
during  the  night  Avas  too  warm,  so  that  she  was  quite  restless.  While 
half  awake  she  suddenly  turned  in  bed,  when  she  felt  "  something 
move  inside  of  her."  She  became  nauseated, and  vomited;  the  pros- 
tration was  so  marked  that  I  was  called  up  to  see  her,  and  found  her 
in  collapse.  In  a  few  hours  she  reacted  ;  a  violent  chill  then  occurred, 
followed  by  fever,  and  her  pulse  increased  to  130  per  minute.  During 
the  day  her  fever  continued,  but  she  was  relieved  of  pain  in  the  abdo- 
men by  the  use  of  opium  and  hot  applications.  On  the  following  day, 
April  1st,  during  the  forenoon,  she  had  another  chill,  but  it  was  not 
as  violent  as  the  previous  one.  At  3  P.M.,  her  pulse  being  120,  the 
skin  began  to  be  moist,  and  she  exhibited  other  indications  of  blood 
poisoning.  Ten  grains  of  quinine  were  given  at  9  P.  M.  ;  this  dose 
was  repeated  at  12  P.  M.,  her  pulse  having  then  fallen  to  110;  the 
same  quantity  was  administered  at  8  A.M. 

April  2.  9A.M.  The  quinine  was  not  given  as  the  stomach  was 
irritable.  The  pulse  had  fallen  to  106,  but  as  its  character  was  in- 
dicative of  a  loss  of  power,  she  was  ordered  iced  champagne.  Dr. 
T.  G.  Thomas  saw  the  case  in  consultation  at  half-past  ten  A.  M.  The 
temperature  of  the  body  was  then  105°,  and  a  jaundiced  tint  of  the 
skin  was  noticed  for  the  first  time.  There  had  been  three  slight 
movements  from  the  bowels  since  my  last  visit,  which  were  attributed 
to  the  peritonitis.  The  condition  of  the  stomach,  however,  had  greatly 
improved.  It  was  decided  to  return  to  the  quinine  in  doses  of  three 
grains,  every  six  hours.  She  was  to  take  five  drops  of  nitro-muriatic 
acid,  every  three  hours,  and  milk  punch  in  such  quantities  as  she  could 
bear,  and  at  such  intervals  as  seemed  to  be  indicated.  A  vaginal 
examination  was  made,  but  nothing  ascertained  beyond  the  existence 
of  an  extensive  cellulitis  on  the  left  side.  The  pulse  gradually  di- 
minished in  frequency,  and  the  condition  of  the  skin  was  remarkable, 
for  while  the  temperature  in  the  axilla  or  vagina  was  from  104°  to 
105°,  the  sense  of  touch  could  detect  no  unusual  elevation  on  the 
general  surface.  She  was  sweating  moderately  all  the  time  from  blood 
poisoning,  but  where  the  body  was  not  covered,  the  temperature  on 
the  surface  was  lowered  by  evaporation.  Without  the  use  of  the 
thermometer  we  should  have  had  no  knowledge  of  her  critical  con- 
dition, for  she  no  longer  suffered  from  pain,  and  had  been  without 
opium  for  nearly  twenty -four  hours. 

3cZ.  The  gene'ral  condition  had  improved,  the  temperature  had  fallen 
to  108°,  the  pulse  to  90  ;  the  yellow  tinge  in  the  skin  had  become 
less  marked  ;  there  was  no  longer  nausea,  and  her  nourishment  was 
all  retained,  when  administered  by  either  the  stomach  or  rectum.  Iler 
condition  seemed  so  favorable,  that  Dr.  Thomas  considered  it  unneces- 
sary that  we  should  meet  for  another  consultation.  Throughout  the 
following  day,  April  4,  there  was  no  apparent  change,  with  the  excep- 
tion that  her  strength  was  evidently  not  so  good,  and  at  times  it  seemed 
that  her  mind  wandered,  although   she  was  perfectly  rational  when 


ENLARGEMENT  OF  THE  OVARY.  751 

spoken  to.  About  half-past  one  A.M.,  April  5,  she  sank  into  a 
collapse  as  siuldenl}'  as  at  the  beginning,  but  did  not  react,  and  died 
at  six  o'clock  A.M. 

Five  hours  after  death  the  autopsy  was  made,  and  by  request  it 
was  confined  to  the  abdominal  cavity.  General  peritonitis  existed, 
and,  in  the  pelvis,  on  the  right  side,  and  around  the  intestines,  was 
found  a  quantity  of  free  pus.  It  was  evident  tiiat  the  ovary  had  long 
been  the  seat  of  an  abscess,  which  had  gradually  destroyed  the  whole 
org-an,  so  that  nothino;  remained  of  it  but  a  sac.  Nature  had 
attempted  a  repair  by  encysting  the  sac,  so  that  in  all  probability  the 
contents  of  the  abscess  would  have  escaped  into  the  rectum  at  some 
future  time,  if  the  rupture  into  the  peritoneal  cavity  had  not  been 
caused  by  the  sudden  effort  of  turning  in  bed.  Notwithstanding  the 
symptoms  of  blood-poisoning,  which  were  evident,  she  had  begun  to 
improve.  As  ample  adhesions  had  taken  place,  the  newly-formed 
pelvic  abscess  would  eventually  have  opened  into  the  rectum  or  vagina, 
and  so  she  might  have  recovered,  but  the  second  unfortunate  rupture 
of  the  sac  into  the  peritoneum  induced  a  shock  from  which  she  had 
not  the  strength  to  rally. 

Enlargement  of  the  Ovary. — In  chronic  inflammation  of  the  ovary 
the  organ  is  generally  enlarged,  and  when  free  from  adhesion  it  pro- 
lapses, more  or  less,  from  the  increased  weight.  It  may  occupy  any 
point  between  its  natural  position  and  the  bottom  of  Douglas's  cul-de- 
sac,  so  long  as  it  does  not  exceed  twice  its  natural  size.  Where  it  has 
become  hypertrophied  to  a  greater  degree,  which  is  very  unusual,  it 
cannot  reach  so  low  a  position  in  the  pelvis,  and  will  be  the  more 
likely  to  form  adhesions.  As  with  an  inflamed  testicle,  the  slightest 
pressure  upon  such  an  ovary  will  produce  pain,  and  frequently  nausea. 
The  uterus  is  also  enlarged,  the  cervix  the  seat  of  an  erosion,  and  the 
organ  itself  is  generally  retroverted  when  the  ovary  is  prolapsed. 

A  movement  of  the  bowels  will,  for  a  time,  increase  the  suffering 
in  consequence  of  the  relation  of  the  rectum  to  the  left  ovary,  this 
being  the  one  which  is  usually  affected.  There  will  be  an  inability, 
on  the  part  of  the  patient,  to  exercise  or  to  stand  for  any  length  of 
time  without  adding  to  the  feeling  of  discomfort. 

There  will  be  dysmenorrhoea,  with  the  menstrual  flow  irregular  both 
in  duration  and  quantity.  The  surface  of  the  ovary  is  usually  smooth, 
while  its  texture  is  soft  and  boggy  when  the  disease  has  not  been  of 
long  duration.  This  condition  frequently  makes  its  appearance  early 
in  menstrual  life,  and  if  not  relieved  Avill  in  time  be  complicated  by 
attacks  of  local  peritonitis,  or  cellulitis.  Ultimately  the  size  of  the 
ovary  becomes  greatly  reduced  and  its  surface  roughened  or  corru- 
gated. Menstruation,  which  may  have  been  previously  too  free,  will 
now  become  scanty   and  irregular.     A  woman  subjected  to  either 


752  DISEASES    OF    THE    OVARIES. 

stage  of  this  disease  will  seldom,  if  ever,  be  entirely  free  from  pain  at 
any  time  throughout  the  menstrual  month.  But  at  the  time  of  the 
flow  all  the  symptoms  will  be  greatly  aggravated ;  so  much  so  that 
the  existence  of  active  inflammation  will  seem  to  be  indicated  by  the 
occurrence  of  a  chill,  the  increase  of  pulse,  the  pain,  and  pyrexia. 

Under  other  circumstances  there  will  be  no  prolapse  of  the  ovary, 
or  even  an  appreciable  enlargement,  for  the  oi-gan  will  remain  beyond 
the  reach  of  the  finger.  Yet  the  same  disturbance  of  the  nervous  system 
will  exist,  menstruation  will  be  as  irregular,  while  the  constant  pain 
in  the  neighborhood  of  the  ovaries  and  every  other  symptom  will  indi- 
cate that  the  same  state  of  disease  or  irritation  has  been  established 
in  both  conditions. 

With  all  these  various  diseases  the  general  health  is  greatly  im- 
paired, and,  as  a  rule,  a  profound  degree  of  anaemia  exists. 

Dr.  Barnes^  states:  "We  can  hardly  conceive  an  inflammation  of 
the  ovary,  which  recurs  every  month  throughout  thirty  yea.rs,  and 
which  is,  nevertheless,  compatible  with  the  continuance  of  the  ovarian 
function.  These  symptoms,  then,  which,  outside  the  menstrual  epoch, 
would  be  considered  to  indicate  inflammation  of  the  ovary,  may  be 
produced  by  temporary  hypersemia  and  hypersesthesia  of  the  organ." 

These  views  express  very  perfectly  my  own  convictions.  Often 
with  every  symptom  to  indicate  a  local  disease,  there  will  be  no  dis- 
ease whatever  in  the  ovaries,  or  if,  by  chance,  some  morbid  change  be 
detected,  it  will  be  but  an  effect  of  disease  elsewhere. 

The  various  symptoms  of  ovai-ian  disorders  are  but  an  evidence  that 
nature's  laws  have  been  put  at  defiance,  and  that  the  nervous  system 
has  been  overtaxed. 

Who  are  the  sufferers  from  the  condition  which  has  been  termed  an 
irritable  ovary  ?  The  young  girl  who  has  had  her  brain  developed 
out  of  season ;  the  woman  disappointed  or  crossed  in  love  by  some 
man  not  worthy  of  her ;  those  who  have  been  ill  mated,  and,  often, 
the  unmated ;  she  who  has  sold  her  person,  under  the  guise  of  mar- 
riage, for  money  or  position ;  the  prostitute,  and  she  who  degrades 
herself,  and  sacrifices  her  womanhood  by  resorting  to  means  to  pre- 
vent conception.  In  all  of  these,  the  nervous  system  has  been  first 
abused,  and  then  nutrition  has  sufi'ered  ;  some  accident  only  locating 
the  effects  in  the  ovary. 

We  are  unable  to  explain  the  fact  that  the  extent  of  disease  may 
be  limited  to  what  may  be  termed  a  congestive  enlargement,  due  to 

'  Diseases  of  Women,  American  edition,  p.  262. 


TREATMENT.  753 

obstruction  in  the  venous  circulation.  The  enhargement  is  cvidentlj 
not  from  arterial  congestion,  for  that  would  tend  to  inflammation, 
which,  if  continued,  leads  to  the  breaking  down  of  tissue,  and  the 
formation  of  abscess.  This  venous  congestion  may  last  for  years,  and 
from  some  unknown  cause  the  ovary  may  be  prolapsed,  but  only  as 
an  exception  to  the  rule,  for  an  ovary  equally  large  and  as  free  from 
adhesions  will  more  frequently  remain  in  place.  Under  this  conges- 
tive influence  the  organ  undergoes  cystic  degeneration,  and  remains 
stationary  at  nearly  the  same  degree  of  enlargement  for  years.  A 
rarer  change  is  an  early  atrophy  which  presents  the  appearance  of 
cirrhosis,  but  this  has  been  already  referred  to. 

Ovulation  in  an  ovary  in  either  of  these  conditions  is  generally 
imperfect,  and  is  attended  with  dysmenorrhoea  and  other  menstrual 
disorders. 

Treatment. — It  is  difficult  to  afford  any  marked  relief  during  the 
menstrual  life  of  the  woman.  Within  the  whole  range  of  the  dis- 
orders to  which  women  are  liable,  none,  as  a  rule,  present  so  un- 
promising an  outlook  as  this,  for  both  patient  and  physician. 

A  serious  state  of  anaemia  exists  in  all  these  cases,  and  the  condi- 
tion has  already  long  reached  a  stage  when  it  would  be  of  little 
importance  to  determine  what  is  the  cause  and  what  the  effect.  The 
close  relation  existing,  through  the  sympathetic  system,  between  the 
generative  function  and  general  nutrition  has  already  been  treated  of. 
During  the  menstrual  life  of  a  woman,  the  dominant  power  is  the 
influence  emitted  from  the  ovaries,  and  when  normally  exercised  is 
a  most  potent  stimulus  to  healthy  nutrition.  It  can  then  be  readily 
understood  that  to  correct  this  extreme  state  of  anaemia,  while  ovula- 
tion itself  is  so  imperfect,  must  be  difficult.  After  the  menopause, 
however,  the  sympathetic  nerves  again  become  dormant,  in  their 
relation  to  sexual  functions,  as  before  puberty,  and  an  attempt  is  at 
once  made  to  correct  and  repair  the  defects  in  nutrition. 

There  are  many  cases  where,  by  judicious  treatment  at  an  early 
stage,  health  can  be  regained.  In  other  instances,  I  have  known  the 
reparative  powers  of  nature  to  prevail,  after  every  artificial  means 
had  been  resorted  to,  and  the  cases  regarded  as  hopeless.  We  should 
then  never  despair  in  any  case.  But  the  prognosis  often  turns  on  the 
degree  of  judgment  Avith  which  the  case  has  been  treated  by  the 
physician  in  charge  of  it  at  the  beginning.  Many  a  woman  has  been 
rendered  incurable  in  consequence  of  the  opium  habit,  contracted  at 
the  instigation  of  an  ignorant  or  careless  medical  adviser.  Of  all 
drugs,  none  is  more  potent  than  morphine  in  producing  anaemia,  and 
48 


754  DISEASES    OF    THE    OVARIES. 

in  causing  by  long  use  a  neuralgia  from  its  own  poisonous  effects.  I 
have  seen  several  instances  of  so-called  oophoritis,  in  which  morphine 
had  been  freely  used  for  years  to  relieve  pain  over  the  region 
of  the  ovaries,  and  in  which,  under  more  judicious  management,  an 
improvement  in  the  general  health  took  place,  and  all  pain  disappeared 
in  two  or  three  months  after  the  opium  habit  had  been  broken  up.  I 
have  no  doubt  that  there  are  cases  of  local  neurosis  due  to  pressure 
exerted  by  the  contraction  of  ovarian  tissue.  In  these  cases  the  pain 
not  only  continues,  but  will  become  worse,  if  the  use  of  anodynes 
be  discontinued.  But  in  the  beginning,  the  ill-judged  use  of  opium, 
doubtless  aids  in  producing  an  angemia  which  would  otherwise  not 
occur;  and  it  may  even  induce  inflammation  of  the  ovarian  tissue, 
through  its  deleterious  influence  on  nutrition.  After  a  certain  stage 
has  been  reached  in  the  use  of  morphine,  but  few  victims  will  have 
the  courage  to  make  a  real  effort  to  get  rid  of  the  evil ;  in  fact,  the 
chances  for  reform  from  the  opium  habit  are  less  promising  than  those 
for  a  full  restoration  of  the  lowest  drunkard  from  the  gutter.  But 
the  attempt  at  reform  must  be  the  first  step,  and  the  habit  must  be 
broken  up  if  possible,  for  as  long  as  it  exists  no  accurate  idea  can  be 
formed  of  the  local  condition. 

To  direct  any  special  course  of  treatment  is  impossible,  since  every 
function  of  the  body  will  be  impaired  to  a  greater  or  less  degree.  The 
one  great  aim  should  be  to  lessen,  if  possible,  the  anaemia.  Drugs 
will  be  of  little  service  at  first,  but  we  may  accomplish  much  by  sun- 
light and  fresh  air.  Whenever  the  circumstances  will  admit  of  it,  the 
patient  should  expose  her  whole  body  to  the  sunlight,  so  as  to  secure 
its  active  effect  on  the  blood  in  the  capillaries,  and  the  longer  the 
better.  Should  she  be  too  feeble  to  get  about,  she  must  be  carried 
into  the  open  air  in  favorable  weather,  to  remain  from  morning  until 
night.  Hot  water  vaginal  injections  must  be  given  night  and  morn- 
ing, and  such  other  appropriate  measures  instituted  as  have  been  fully 
detailed  under  the  head  of  general  principles.  A  change  to  a  milder 
climate  in  the  winter  will  aid  greatly  in  removing  the  state  of  anaemia. 
Yet,  after  all,  we  will  meet  with  a  certain  number  of  cases  where  every 
measure  will  fail,  and  the  irritation  will  become  gradually  concentrated 
in  the  disturbance  of  the  healthy  action  of  some  nerve  centre.  We 
may  then  have  epilepsy,  or  even  insanity  as  a  consequence,  and  for 
the  relief  of  which  no  rule  can  be  laid  down. 

Battey^s   Operation. — Dr.  Robert  Battey,  of  Georgia,  in  1872, 
reported^  a  case  of  extirpation  of  the  ovaries,  and  recommended  the 

'  Atlanta  Medical  and  Surgical  Journal. 


battey's  operation.  755 

operation  for  the  relief  of  cases  of  imperfect  ovulation  marked  by  an 
"  excessive  menstrual  molimcn."  The  operation  -was  termed  "  Normal 
Ovariotomy,"  and  Avas  only  to  be  resorted  to  after  all  other  means  of 
cure  had  failed.  The  source  of  irritation,  it  Avas  conceived,  would  be 
removed  by  the  cessation  of  ovulation,  brought  a])Out  by  the  extirpa- 
tion. His  views  have  been  imperfectly  understood,  and  as  the  success 
has  not  exceeded  some  twenty-five  per  cent.,  and  as  there  has  been  a 
considerable  mortality  attending  it,  the  operation  has  not  yet  been 
accepted  by  the  profession. 

In  a  recent  paper,^  Dr.  Battey  states:  "  In  doing  these  operations 
I  have  sought  to  eifect  a  cure  of  the  varied  maladies  complained  of, 
by  the  removal,  in  certain  instances,  of  an  ovary  viciously  or  abnor- 
mally performing  its  functions,  and  more  frequently  by  the  removal 
of  both  ovaries,  to  put  an  end  to  ovulation  entirely,  and  thus  to  deter- 
mine the  menopause,  or  change  of  life  ;  whereby  I  have  hoped,  through 
the  intervention  of  the  great  nervous  revolution  which  ordinarily  ac- 
companies the  climacteric,  to  uproot  and  remove  serious  sexual  dis- 
orders, and  re-establish  the  general  health."  The  operation  was 
supposed  by  many  to  have  been  also  recommended  for  the  relief  of 
nymphomania.  This  has  been  distinctly  stated  as  not  being  correct, 
since  "there  is  no  reason  to  expect  its  cure  by  the  arrest  of  ovu- 
lation." 

The  operation  was  performed,  in  most  of  the  cases,  with  the  patient 
on  the  left  side,  and  by  the  aid  of  Sims's  speculum.  The  cervix 
was  drawn  down  to  the  pubes  by  means  of  a  strong  hook,  where  it 
was  held  while  Douglas's  cul-de  sac  was  opened  from  the  vagina  by 
means  of  a  pair  of  scissors.  On  reaching  the  ovary,  with  the  finger 
as  a  guide,  it  was  seized  by  forceps  or  tenaculum,  and  drawn  out  into 
the  vagina.  It  was  then  separated  by  the  dcraseur,  or,  being  secured 
by  a  silk  ligature,  it  was  cut  off,  and  the  stump  returned  into  the 
cavity,  the  opening  being  left  to  close  gradually,  so  as  to  admit  of 
drainage. 

The  position  of  the  patient  causes  the  intestines  to  gravitate  so 
that  they  are  out  of  the  way  during  the  operation.  The  cul-de-sac 
is,  however,  generally  empty,  under  ordinary  circumstances,  and  after 
the  operation  the  presence  of  the  stump  and  rapid  adhesions  prevent 
a  prolapse  of  the  intestines  into  the  vagina.  The  operation  can  be 
readily  done  in  this  position,  so  long  as  the  ovary  happens  to  be  free 
from  adhesions.     When  adhesions  exist  the  ovary  is  to  be  removed 

•  Transactions  of  the  American  Gynecological  Society,  vol.  i.  p.  102. 


Operations. 

Deaths 

.    12 

2 

.     2 

0 

.      2 

0 

.      1 

0 

.      2 

1 

.      1 

1 

.      1 

0 

.      7 

1 

756  DISEASES    OF    THE    OV/rIES. 

by  gouging  it  out  piecemeal  with  the  finger  nail.  The  clanger  of 
hemorrhage  then  presents  itself,  and  may  be  beyond  control,  and  there 
is  a  possibly  incomplete  removal  of  the  ovary.  Dr.  Battey  has  thus 
far  reported  ten  operations  by  the  vagina,  and  two  by  abdominal 
section. 

Dr.  Sims  has  recorded^  his  experience,  and,  after  presenting  all  the 
cases  which  have  been  operated  on  by  others,  has  decided  in  favor  of 
the  operation.     These  cases  are  reported  as  follows :  — 

Dr.  Battey,  Georgia 
Prof.  Hegar,  Freiburg 
Dr.  Trenholme,  Montreal 
Dr.  Gilmore,  Alabama     . 
Dr.  Thomas,  New  York    . 
Dr.  Peaslee,  New  York    . 
Dr.  Sabine,  New  York 
Dr.  Sims,  New  York 

28  5 

He  then  states:  "The  inferences  that  I  draw  from  this  analysis 
of  Battey's  and  my  own  operations  are  these : — 

1st.  Remove  both  ovaries  in  every  case. 

2d.  As  a  rule,  operate  by  abdominal  section,  because  if  the  ovaries 
are  bound  down  by  adhesions,  it  is  possible  to  remove  them  entire, 
whereas  by  the  vaginal  incision  it  is  impossible. 

3d.  If  we  are  sure  that  there  has  been  no  pelvic  inflammation,  no 
cellulitis,  no  hsematocele,  no  adhesions  of  the  ovaries  to  the  neigh- 
boring parts,  then  the  operation  may  be  made  by  the  vagina,  but  not 
otherwise."^ 

1  have  never  performed  the  operation,  and  have  always  refused  my 
consent  to  it  except  as  the  last  resort.     My  experience  of  the  opera- 

'  Battey's  Operation,  by  J.  Marion  Sims,  A.M.,  M.  D.,  British  Medical  Journal, 
December,  1877. 

2  In  his  paper  on  the  removal  of  the  ovaries  for  uterine  fibroids,  or  spaying,  as 
he  calls  it,  Dr.  Goodell  (^Am.  Journ.  of  Med.  Sci.,  July,  1878)  reports  six  cases  in 
addition  to  those  collated  by  Dr.  Sims — one  by  Nussbaiim,  two  by  himself,  and 
three  by  Dr.  Engelman,  in  all  thirty-four,  not  including,  of  course,  those  for 
ovarian  cysts  or  other  tumors.  Of  these,  seventeen  were  operated  on  by  the 
abdominal  section,  of  which  ten  died,  and  seventeen  by  vaginal  incision,  of  which 
only  two  died.  Dr.  Goodell,  therefore,  prefers  the  vaginal  method,  and  if  he  found 
it  impossiljle  to  remove  the  ovaries  in  that  direction  on  account  of  adhesions  or 
other  causes,  he  would  resort  to  the  abdominal  section,  leaving  the  vaginal  incision 
for  deep  drainage.  Tliis  i)aper  has  already  been  alluded  to  in  the  chapter  on  the 
Surtrical  Treatment  of  Fibrous  Tumors  of  the  Womb. 


battey's  operation.  757 

tion  has  been  limited  to  one  by  Dr.  Thomas,  where,  although  both 
ovaries  were  removed,  the  Avoman  was  only  temporarily  benefited,  and 
one  by  Dr.  Peaslee  which  resulted  in  death.  I  agree  with  Dr.  Sims 
as  to  the  necessity  of  removing  both  ovaries  if  the  operation  is  called 
for,  since  it  is  evident  from  the  records  before  us  that  a  favorable 
result  is  not  to  be  expected  unless  cessation  of  ovulation  is  accom- 
plished. Until  the  proportion  of  deaths  is  much  lower,  and  that  of 
benefit  increased,  the  class  of  cases  must  remain  a  very  limited  one 
in  which  a  resort  to  this  hazardous  operation  would  be  justifiable.  Fu- 
ture observation  must  also  demonstrate  that  the  result  of  producing 
an  artificial  change  of  life  has  a  beneficial  effect  on  the  nervous 
system. 

With  my  present  knowledge  of  the  yet  unsatisfactory  results,  my 
consent  to  the  operation  would  be  limited  to  cases  of  threatened  in- 
sanity, epilepsy,  or  phthisis.  For  nervous  disturbances  which  present 
more  of  the  hysterical  element,  the  operation  should  never  be  thought 
of.  In  many  such  apparently  desperate  cases  I  have  seen  a  little 
moral  suasion,  administered  Avith  firmness,  accomplish  a  great  deal, 
and  nature  will  often,  when  aided,  bring  about  a  favorable  change  in 
nutrition  when  least  expected.  The  operation  may  be  more  frequently 
necessary  in  the  present  generation  than  it  ought  to  be  in  the  future, 
since  a  large  number  of  cases  calling  for  it  have,  under  injudicious 
management,  been  already  rendered  incurable  by  other  means.  But 
I  hold  that  in  the  future  this  ouo;ht  not  to  be  so,  for  our  enlarged 
opportunity  for  acquiring  wisdom  in  the  treatment  of  uterine  and  ova- 
rian diseases  should  enable  us  to  raise  our  patients  above  the  neces- 
sity for  such  a  terrible  ordeal. 


758  TUMORS    OF    THE    OVARY 


CHAPTER    XXXVII. 

TUMORS  OF  THE  OVARY. 

Solid  (fibrous)  tumors — Cystic  tumors  :  follicular  cjsts ;  compound  cjstomata  ; 
myxoid  and  dermoid  cystomata ;  cystoma  proliferum  papillare ;  C.  parvilocn- 
lare ;  C.  sarcomatosum  (cystosarcoma)  ;  C.  myxomatosum — Retrograde  meta- 
morpliosis  of  cystomata :  fatty,  sclerotic,  atrophic,  hemorrliagio,  purulent, 
spontaneous  perforation — Development  of  cystomata. 

These  may  be  divided  into  solid  and  cystic  tumors.  The  solid 
tumors  may  be  subdivided  into  fibrous,  cancerous,  and  sarcomatous  ; 
and  the  cystic  tumors  into  follicular  cysts,  dermoid  cysts,  and  ovarian 
cystomata. 

Solid  tumors. — These  are  exceedingly  rare,  slow  of  growth,  and 
seldom  reach  a  large  size. 

Fibrous  tumors  of  the  ovary,  unlike  those  in  uterine  tissue,  in- 
volve the  whole  gland  ;  they  frequently  undergo  partial  degeneration 
into  bony  and  sometimes  cartilaginous  structures.  It  is  often  difiicult 
to  make  a  diagnosis  between  fibrous  ovarian  tumor  and  pedunculated 
fibrous  tumor  of  the  uterus,  and  the  former  can  be  distinguished  from 
a  cystic  tumor  of  the  ovary  only  by  the  difference  in  density. 

A  woman  with  a  fibrous  tumor  of  the  ovary  may  suffer  a  certain 
amount  of  disturbance  from  pressure,  but  as  the  growth  is  slow,  and 
seldom  reaches  any  magnitude,  there  will  be  little  call  for  interference. 
Sometimes,  however,  its  removal  may  be  necessary,  as  local  perito- 
nitis may  follow  and  cause  ascites,  and  the  tumor  may  attain  such  a  size 
and  weight  as  to  demand  removal. 

The  operation  for  the  removal  of  an  ovarian  fibrous  tumor  must 
necessarily  be  the  same  in  principle  as  that  to  be  described  hereafter 
under  the  head  of  ovariotomy. 

I  have  met  with  several  supposed  fibrous  tumors  of  the  ovary,  but 
they  were  all  too  small  to  call  for  any  interference.  The  only  cases 
on  record  in  this  country,  where  the  fibrous  tumor  had  reached  a  size 
making  its  removal  necessary,  were  two  opei-ated  on  by  Dr.  Wm.  H. 
Van  Buren  of  this  city,  one  in  1849,  and  the  other  in  1850.  Dr. 
Peaslee,  in  his  work  on  Ovarian  Tumors,  gives  Dr.  T.  G.  Thomas  the 


SOLID    TUMORS.  759 

credit  of  having  also  removed  such  a  tumor,  but  Dr.  Thomas^  regards 
the  case  as  having  been  one  of  "  true  cysto-fibroma."  I  removed  an 
apparently  solid  tumor  as  large  as  an  adult's  head  in  May,  1876,  from 
a  patient  in  Brooklyn,  under  the  care  of  Dr.  Joseph  C.  Hutchison, 
which  -was  supposed  to  have  been  a  fibrous  tumor  of  the  ovary,  by 
Dr.  Peaslee  and  myself,  who  had  watched  the  case  together  for  five 
or  six  years.  But  on  examination  under  the  microscope,  it  proved  to 
be  a  myo-adeno- cystoma,  or  a  granular  cyst  tumor  of  the  ovary,  con- 
taining muscular  fibres.  This  case  is  referred  to  for  the  purpose  of 
showing  the  difficulty  of  diagnosis,  and,  it  may  be  added,  to  illustrate 
how  doubtful  is  the  diagnosis  of  all  fibrous  tumors  of  the  ovary  which 
have  attained  a  large  size. 

Schroeder^  states  that  "  it  is  still  doubtful  whether  only  true  fibro- 
mata occur  in  the  ovary,  or  myo-fibromata  also,  since  it  is  extremely 
difficult  to  decide  even  in  the  cadaver,  whether  the  fibroid  has  origi- 
nated from  the  uterus  or  the  ovary."  Again,  "It  is,  therefore,  still 
a  matter  of  doubt  whether  the  true  myo-fibromata  do  not  always  arise 
from  the  uterus,  the  true  fibromata  alone  being  of  ovarian  origin. 
Virchow  considers  that  myo-fibromata  occur  in  the  ovary,  but  that 
the  smooth  muscular  fibres  are  only  sparsely  found  in  them." 

Some  writers  regard  these  tumors  of  the  ovary  as  being  malignant 
in  character,  especially  when  accompanied  by  ascites,  but  I  question 
the  fact,  since  I  have  not  had  such  a  case  under  observation  for  many 
years. 

It  might  be  very  difficult  to  form  a  diagnosis  between  an  ovarian 
fibroid  and  cancer  of  this  organ,  especially  if  there  should  be  any 
fluid  in  the  abdominal  cavity.  We  should,  however,  expect  a  fibroid 
to  be  more  movable  than  an  ovary  which  had  undergone  cancerous  in- 
filtration, since  the  latter  process,  by  exciting  irritation,  must  give 
rise  to  adhesions.  It  is  also  stated  by  observers  that  a  fibroid  retains 
more  the  shape  of  the  organ,  while  in  cancer  of  the  ovary  the  sur 
rounding  tissues  become  so  involved,  that  the  mass  is  soon  broader 
and  thinner  than  with  a  fibroid.  Moreover,  cancer  is  rarely  if  ever 
confined  to  one  ovary. 

Instances  of  scirrhus  and  sarcoma  of  the  ovary  'have  been  nlet 
with,  of  gi'eat  interest  to  the  pathologist  doubtless,  but  of  little  practi- 
cal import,  since,  however  great  the  necessity,  we  lack  the  means  to  dif- 
ferentiate during  life  between  the  several  forms  of  malignant  disease. 

'  Thomas  on  Diseases  of  Women,  p.  655,  4th  edition. 
*  Ziemssen's  Cyclopaedia,  vol.  x.  p.  437.     N.  Y.  edition. 


760  TUMORS  OF  THE  OVARY. 

I  have  never  met  with  an  instance  of  any  form  of  malignant  disease 
which  was  confined  to  the  ovary.  In  fact,  when  the  ovaries  are 
involved,  it  is,  as  it  were,  the  last  stage  of  some  contiguous  dis- 
ease in  which  the  rest  of  the  pelvic  tissues  will  have  already  become 
involved. 

Cystic  Tumors  of  the  Ovary. 

Follicular  cysts  are  the  most  common,  and  at  the  same  time  the 
least  important  of  the  cystic  growths  connected  with  the  ovary.  They 
rarely  ever  reach  a  size  to  produce  inconvenience,  or  to  be  recognized 
.during  life.  According  to  Schroeder,^  "the  dropsy  of  the  Graafian 
follicle  represents  a  so-called  retention-cyst,  and  is  to  be  considered 
in  the  same  group  with  tubal  dropsy,  h^matometra,  etc."  "  They 
occur  singly,  or  the  whole  ovary  becomes,  through  a  repetition  of  the 
same  process  in  numerous  Graafian  follicles,  converted  into  a  tolerably 
large  tumor,  which  presents  on  section  a  multilocular  cystic  appear- 
ance" (Waldeyer).  These  cysts  have  a  smooth  wall,  no  projecting 
septa,  and  their  contents  consist  of  a  clear,  transparent  serum.  The 
origin  of  the  cysts  is  doubtless  partly  owing  to  the  causes  which  hinder 
the  rupture  of  the  follicle.  Sometimes,  when  a  follicle  is  physiologi- 
cally mature,  rupture  fails  to  take  place,  either  because  the  ovum  has 
not  progressed  towards  the  free  surface  of  the  ovary,  or  because  the 
surface  of  the  ovary  is  covered  with  an  exudation,  the  product  of  some 
inflammatory  process,  which  prevents  the  rupture  taking  place.  In 
many  cases,  doubtless,  the  follicle  is  obliterated,  but  the  secretion 
may  remain,  and  so  give  rise  to  the  production  of  a  cyst.  It  is,  more- 
over, possible,  as  Rokitansky  (^Allgi  Wiener  Med.  Z.,  1859,  No.  34, 
Lehrb.,  3  Aufl.,  p.  48)  first  demonstrated,  for  a  cyst  to  form  from  a 
ruptured  Graafian  follicle,  in  other  words,  from  a  corpus  luteum, 
probably  in  this  way ;  after  the  closure  of  the  opening  where  the  rup- 
ture took  place,  and  after  the  formation  of  the  corpus  luteum,  the 
latter  becomes  a  cyst.  I  have  myself  seen  one  such  case,  in  which 
there  was  a  cyst  of  the  corpus  luteum  in  the  ovary  of  a  patient  who 
had  died  of  hemorrhage  during  a  miscarriage.  Next  to  the  wall  of 
the  cyst  came  the  yellow  layer  of  the  corpus  luteum,  and  then  the 
white  coat  of  the  ovary. 

Compound  Cystomata. — But  little  exact  knowledge  has  yet  been 
attained  in  regard  to  the  cause  or  origin  of  these  growths. 

'  Ziemsseii's  Cycloprcdia,  Am.  ed.,  vol.  x.  p.  362. 


CYSTIC    TUMORS.  7G1 

No  author,  from  his  own  observation,  has  heretofore  described  tlicir 
condition  Avith  so  much  clearness  as  Wahleyer.^ 

Schroeder  (^Ziemssen^s  CydojJcedid)  has  briefly  given  these  views, 
but  in  no  other  form,  to  my  knowledge,  have  they  reached  the  Eng- 
lish reader.  I  regard  the  subject,  as  presented  by  Waldeyer,  to  be 
of  sufficient  importance  to  give  his  views  at  greater  length  than  has 
been  done,  and,  while  they  will  not  be  quoted  literally,  the  remainder  of 
the  chapter  Avill  be  devoted  to  presenting  them  in  substance. 

Waldeyer,  who  designates  the  compound  cystic  growths  of  the 
ovary  as  "  Cystomata,"  subdivides  these  tumors  into  two  essentially 
different  groups,  viz.: — 

(a)  Myxoid  Cystomata,  of  which  the  inner  surface  exhibits  quite  the 
appearance  and  behavior  of  an  ordinary  mucous  membrane  abundantly 
provided  with  glands  and  vessels,  and 

(/>)  Dermoid  Cystomata,  of  which  the  inner  surface  shows  the  cha- 
racter of  an  exte-rnal  skin  invested  with  epidermis. 

The  Myxoid  Cystomata  usually  form  large  unilocular  or  multi- 
locular  sacs,  of  the  size  of  a  man's  head  and  larger,  so  that  they  may 
contain  as  much  as  fifty  to  a  hundred  quarts  (litres)  of  fluid.  They 
may  appear  on  one  side  or  on  both  sides.  The  pedicle  of  these  tumors 
is  formed  by  the  ligamentum  ovarii,  the  tube,  and  the  ligamentum 
latum,  the  latter  containing  numerous  vessels,  often  very  large.  The 
longer  and  thinner  the  pedicle,  the  firmer  is  it  apt  to  be,  and  it  contains 
pre-eminently  fibrillary  connective  tissue,  and  a  few  smooth  muscular 
fibres.  In  rare  cases  the  pedicle  is  entirely  wanting,  and  the  ovarian 
tumor  sits  immediately  on  the  uterus  with  a  broad  base.  The  com- 
ponents of  the  cystomata  are  the  main  cystic  Avails,  the  secondary 
cysts,  the  proliferations  of  the  inner  and  external  surface,  and  the 
cystic  contents,  generally  fluid. 

The  main  cystic  wall,  inclosing  all  the  other  structures,  forms  the 
external  boundary  of  the  tumor,  and  usually  incloses  also  a  main 
cystic  space  which  has  always  been  formed,  perhaps,  by  a  confluence 
of  several  smaller  primary  cysts.  Into  this  main  cyst  project  almost 
all  the  secondary  cysts,  and  from  its  wall  stand  most  of  the  glandular 
and  papillary  vegetations,  and  it  also  conceals  the  principal  mass  of 
the  contents.  The  older  the  cystoma,  the  larger  in  general  becomes 
the  principal  cystic  space,  and  finally  the  cystoma  becomes  unilocular, 
all  the  secondary  cysts  being  blended  with  the  chief  cyst.  In  the 
smaller  or  younger  cystomata,  it  is  true,  a  principal  cystic  space  can- 

'  See  Archiv  fiir  Gyn3ekologie.     Erster  Band,  Zweite  Heft,  s.  252. 


762  TUMORS  OF  THE  OVARY. 

not  be  discriminated,  and  thej  form  rather  solid  walls,  on  the  section 
of  which  we  find  numerous  small  cysts  with  gelatinous  contents.  The 
blending  process  of  the  secondary  cysts,  with  the  principal  cyst,  is  first 
of  all  introduced  by  a  thinning  of  the  walls  of  the  secondary  cysts, 
incident  to  their  growth.  Later  a  perforation  takes  place  into  the 
principal  cyst,  or  into  a  neighboring  secondary  cyst,  after  which  the 
perforated  cyst  ceases  to  grow,  and  atrophies.  The  opening  that  has 
originated  becomes  larger  and  larger,  and  the  space  within  the  opened 
cyst  becomes  flatter  and  flatter,  until  at  last  only  a  flat  dish-shaped 
depression  remains  in  the  wall  of  the  principal  cyst.  The  formations 
appearing  by  further  development  on  the  inner  surface  of  the  principal 
cystic  w^all  are,  in  a  certain  series  of  cases,  pre-eminently  of  a  glan- 
dular nature,  and  in  the  sections  through  the  cystic  wall  everywhere 
show  small,  single,  tubular  epithelial  recesses,  and  in  this  way  the 
cystoma  proliferum  glandulare  originates.  The  openings  of  these 
tubules  are  soon  obliterated  by  the  tenacious  secretion,  and  thus  dila- 
tations originate  that  are  transformed  into  just  so  many  small  cysts, 
like  retention-cysts.  New  glandular  formations  soon  proliferate  from 
the  inner  surface  of  these  small  cysts,  and  this  process  advances  in 
continuing  succession,  so  that  these  small  cysts  are  ranged,  story  upon 
story,  as  it  were,  and  generate  forms  that  have  the  greatest  similarity 
with  a  honey-comb. 

In  other  cases  numerous  villous  and  dendritic  vegetations,  varying 
in  size,  sprout  from  the  inner  surface  of  the  principal  cystic  wall.  In 
some  cases  these  growths  are  limited  to  a  small  space,  only  pro- 
liferating in  places  here  and  there,  but  in  others  they  multiply  to  an 
incredible  degree,  filling  up  the  entire  cystic  sac,  thus  constituting  the 
cystoma  proliferum  papillare.  They  are  generally  very  vascular,  and 
their  basis  consists  of  the  connective  tissue  of  the  inner  layer  of  the 
cystic  wall  well  supplied  with  cells.  In  form  they  are  sometimes  as 
fine  slender  filaments,  or  short  ones,  again  as  broad  or  high  masses, 
ramifying  as  compound  papillae.  At  times  these  vegetations  perforate 
the  principal  cystic  wall,  and  proliferate  in  the  abdominal  cavity. 
Waldeyer  explains  the  fact  that  adhesions  of  these  cystomata  with  the 
neighboring  parts  are  so  rare  by  the  peculiar  nature  of  the  ovarian 
epithelium.  This  consists  of  cylindrical  cells,  which  bestow  upon  the 
surface  of  the  cystoma  the  character  of  a  mucous  membrane,  and,  there- 
fore, prevent  adhesions  forming  so  long  as  the  entire  surface  of  the 
tumor  remains  intact.  But  after  the  epithelium  has  been  lost,  Avhich 
generally  occurs  in  the  larger  cystomata  as  the  result  of  friction 
against  the  abdominal  walls,  inflammation  is  excited,  and  adhesions 


VARIETIES    OF    CYSTS.  703 

take  place  generally  to  the  abdominal  walls,  the  omentum,  and  the 
uterus,  but  rarely  to  the  intestines,  which  are  so  constantly  in  motion. 

The  principal  cystic  walls,  and  the  walls  of  the  somewhat  larger 
secondary  cysts,  consist  of  two  layers,  an  external  connective  tissue 
stratum,  rather  dense,  of  parallel  fibres,  and  a  much  thinner  inner 
stratum,  very  well  provided  with  cells  and  vessels,  on  which  the  epi- 
thelium immediately  sits.  The  smaller  cysts  are  only  surrounded  by 
the  last-mentioned  stratum.  Waldeyer  maintains  that  the  epithelium 
is  always  a  cylindrical  one,  and  covers  the  inner  surface  of  the  cyst 
in  a  single  layer.  Eichwald  states  that  he  found  pavement  epithelium, 
and  others  report  that  they  have  discovered  ciliated  epithelium  in  a  few 
rare  cases.  In  the  glandular  cystomata,  the  epithelium  sinks  from 
point  to  point  into  the  depth  of  the  cyst  walls  in  the  form  of  a  glan- 
dular knob  with  a  central  lumen,  and  thus  forms  flask-like  or  cylin- 
drical glands,  which  are  generally  very  short. 

The  contents  of  ovarian  cysts  generally  consist  of  a  somewhat 
opaque  brownish-red,  or  dirty  yellowish-gray,  dense  stringy  mass,  of 
the  specific  gravity  of  1018-1024.  The  chemical  composition  of  the 
substance  contained  in  these  cysts  will  be  referred  to  hereafter  at 
some  length,  when,  in  comparison  with  that  of  other  abdominal  fluids, 
the  subject  will  be  considered  in  its  relation  to  diagnosis. 

Waldeyer  considers  the  contents  of  the  cysts  to  be  due  in  a  great 
measure  to  a  metamorphosis  of  the  protoplasm  of  the  cells.  This 
metamorphosis  is  very  frequently  attended  with  the  destruction  of  the 
epithelial  cells,  for  if  we  examine  fresh  gelatinous  masses,  lying  im- 
mediately on  the  inner  surface  of  the  cysts,  we  always  find  a  quantity 
of  clear  cells  distended  to  roundish  vesicular-like  forms,  with  a  quan- 
tity of  cell  detritus,  varying  in  size  and  form.  It  is  thought,  in  addi- 
tion, that  each  one  of  these  goblet-shaped  epithelial  cells,  frequently 
present,  may  perform  the  functions  of  a  unicelled  gland  for  a  time, 
until  it  finally  undergoes  destruction.  At  the  same  time  it  is  scarcely 
necessary  to  state  that  an  admixture  of  a  simple  transudate  is  not  to 
be  excluded. 

As  varieties  of  the  cystomata,  "Waldeyer  mentions — 

1.  The  cystoma  parviloculare,  which  is  composed  of  a  great  number 
of  smaller  cysts,  and  constitutes  rather  compact  masses,  with  a  sec- 
tional surface  like  a  honeycomb,  has  an  independent  existence,  or 
constitutes  the  appendage  of  a  large  principal  cystic  space. 

2.  The  cystoma  sarcomatosum  (cystosarcoma  of  the  older  writers), 
in  which  a  sarcomatous  texture  of  the  walls,  especially  of  the  younger 
secondary  cysts,  may  be  perceived,  and — 


761  TUMORS  OF  THE  OVARY. 

3.  The  cystoma  myxomatosum,  in  which  we  find  a  myxomatous 
condition  in  the  inner  layers  of  the  walls  of  the  principal  cysts  and 
secondary  cysts,  and  the  papillary  proliferations  starting  from  them. 

As  processes  of  retrograde  metamorphosis  of  the  ovarian  cystomata, 
Waldyer  describes — 

1.  The  fatty  degeneration  of  the  epithelial  cells  and  the  cells  of  the 
connective  tissue  parietal  stratum,  which  rarely  appears  to  any  great 
extent. 

2.  The  sclerotic  condensations  of  the  connective  tissue  in  the 
principal  cystic  walls. 

3.  The  wasting  away  of  the  cysts,  proceeding  from  the  destruction 
of  all  the  secondary  cysts  and  the  atrophy  of  the  glandular  formations 
of  the  inner  cystic  wall  and  its  epithelium,  with  which  ceases  all 
power  of  proliferation,  and  all  secretion  of  the  cystoma,  the  latter  then 
remaining  stationary.  This  process,  only  observed  in  the  glandular 
cystomata,  is  the  consequence  of  the  pressure  that  the  constantly 
accumulating  cystic  contents  exercise  in  a  certain  toughness  and  un- 
yielding condition  of  the  walls. 

4.  Hemorrhages  in  the  interior  take  place  pre-eminently  in  papillary 
cystomata  from  the  very  vascular  papillary  proliferations. 

5.  The  acute  purulent  inflammations  start  from  the  inner  parietal 
layer  of  the  cystoma  which  is  well  provided  with  cells.  The  abundance 
of  the  cells  is  then  so  increased  that  all  the  fibrous  elements  among 
them  disappear,  the  vessels  are  dilated  and  contain  colorless  blood- 
corpuscles  in  large  number.  In  places  here  and  there,  the  epithelium 
in  large  tracts  is  detached  from  the  wall  of  the  cyst  by  the  pus  cells 
breaking  through  it,  the  pus  pervades  this  epithelium  and  accumulates 
on  its  other  side,  so  that  the  epithelium  is  bathed  by  the  pus  on  both 
sides.  At  the  point  where  the  epithelium  is  detached  from  its  sub- 
stratum vascular  loops  soon  spout  up. 

6.  The  spontaneous  perforations  of  the  cystic  walls,  either  originate 
through  extended  fatty  metamorphosis,  or  the  cause  is  to  be  found  in 
extensive  papillary  proliferations  or  suppurations,  or  gangrenous  dis- 
integration. 

The  ovarian  cystomata  develop  from  a  hyperplastic  formation  of  the 
tubules  of  Pfliiger,  and  consequently  can  be  traced  to  the  epithelial 
constituents  of  the  ovaries ;  they  are  genuine  epitJielial  7ieoj:)lasms. 
Two  histological  elements  are  represented  in  the  ovary  from  its  first 
development,  the  vascular  stroma  and  the  ovarian  epithelium.  The 
mass  of  the  ovary  now  originates  by  a  mutual  intergrowth  of  the 
vascular  stroma  and  the  epithelial  seated,  it  is  true,  in  the  bcginnhig, 


DEVELOPMENT    OF    CYSTS.  765 

only  on  its  surface,  with  a  constant  increase  of  the  two  constituents. 
This  process  lasts  perhaps  up  to  birth.  In  this  manner  a  roundish 
organ,  the  ovary,  grows  in  place  of  the  germinal  epithelium  expansion, 
orginally  quite  flat,  in  which,  from  the  process  of  intergrowth,  a 
quantity  of  epithelial  elements  is  imbedded.  These  lie  in  the  begin- 
ning quite  disordered,  and  densely  crowded  in  the  meshes  of  the 
stroma,  so  that  the  section  of  an  embryonic  ovary  shows  quite  a 
cavernous  structure.  Later,  the  vascular  stroma  increases  more, 
while  the  imbedded  epithelial  heaps  remain  about  equal  in  quantity, 
the  latter,  as  a  matter  of  course,  are  removed  wider  apart.  Many  of 
them  being  segregated  into  round  follicles,  other  epithelial  balls  re- 
main still  a  long  time  united  together  in  the  form  of  a  chain  or  rosary 
(Pflliger's  tubules),  until  also  here,  by  the  continually  advancing 
development  of  the  vascular  stroma,  the  separation  into  individual 
follicles  takes  place  generally  around  an  ovular  cell. 

In  the  development  of  a  cystoma,  we  have  in  the  adult  ovary  quite 
similar  relations,  only  there  are  no  regularly  constructed  follicles  with 
epithelial  cells  and  ova  in  them.  On  the  contrary,  we  find  very 
irregularly  formed  epithelial  deposits  in  the  stroma,  which  is  likewise 
somewhat  increased,  but  they  nowhere  inclose  an  ovum. 

If  it  be  asked  how  these  embryonic  formations  happen  in  the  ovary 
of  an  adult,  the  answer  must  be  either  that  the  first  development  of 
the  ovarian  cystoma  is  to  be  dated  back  to  a  very  early  period,  or 
that  still  later  there  is  also  a  development  of  the  embryonic  forms,  the 
tubules  described  by  Pfliiger.  Both  are  possible,  for  on  the  one  part 
cysts  have  been  observed  in  the  new  born,  and  the  most,  even  the 
largest  ovarian  cystoma,  are  to  be  referred  to  a  relatively  early  period 
of  life.  Yet,  it  cannot  be  denied  that  a  past  embryonic  development 
of  follicular  rudiments  may  appear  as  a  pathological  process.  In 
favor  of  this  view  is  the  appearance,  sometimes  observed  in  rather  old 
women,  of  small  cysts,  clear  as  water,  situated  close  under  the  surface 
of  the  ovary.  These  are  constructed  quite  like  ordinary  ovarian 
cystomata,  they  never  contain  ova,  and  at  times  stand  in  direct  con- 
nection with  the  superficial  epithelium,  so  that  the  transition  of  the 
superficial  epithelium  into  the  cystic  epithelium  cannot  be  doubted. 
They  are  produced  accordingly  by  an  additional  pathological  implan- 
tation of  epithelium  in  the  stroma.  Moreover,  at  some  time  after 
birth,  remains  of  the  tubules  of  Pfliiger  are  found  in  the  ovary  which 
have  not  been  constructed  into  individual  follicles,  and  these  remnants 
of  tubules  may  very  well  give  rise  to  pathological  transformations. 
Finally  it  is  not  to  be  forgotten,  that  a  new  growth  of  epithelial  cells 


766  TUMOKS  OF  THE  OVARY. 

takes  place  also  in  the  formation  of  the  corpora  lutea,  after  the  evacua- 
tion of  the  ovum,  and  these  are  penetrated  in  an  irregular  form  hj 
connective  tissue  processes  of  the  stroma  containing  vessels.  It  is 
true,  under  normal  relations,  the  epithelial  cells  perish  later  by  fatty 
degeneration,  and  only  the  connective  tissue,  shrunken  to  a  cicatrix, 
remains  as  the  corpus  albicans,  but  under  pathological  relations,  the 
epithelial  cells  may  also  continue  to  exist  and  grow  to  glandular 
masses. 

If  it  be  admitted,  as  Waldeyer  believes  he  long  since  demonstrated, 
that  the  superficial  epithelium  of  the  ovary  is  not  serous  epithelium, 
like  that  of  the  peritoneum,  but  is  a  genuine  mucous  membrane  epi- 
thelium, like  that  of  the  Fallopian  tube,  with  which  it  is  often  con- 
tinuously connected,  the  cylindrical  cells  only  devoid  of  cilia;  and  if, 
in  addition,  it  be  proved  that  the  epithelium  of  the  tubes  of  Pfluger, 
and  of  the  Graafian  follicles,  is  derived  from  the  superficial  epithelium 
by  a  process  of  intergrowth  ;  and  if  it  is  also  admitted  that  the  pro- 
liferating cystomata  originate  from  the  tubes  of  Pfliiger,  then  the 
epithelial  character  of  these  tumors  is  simultaneously  demonstrated. 

The  further  growth  and  development  of  the  primary  small  cysts 
into  the  large  complicated  tumors  are  to  be  referred  to  the  cyst  wall 
itself.  In  many  of  the  primary  epithelial  formations,  scarcely  yet 
distended  to  cysts,  as  well  also  in  large  tumors  in  the  smallest  sec- 
ondary cysts,  we  see,  here  and  there,  recesses  in  the  form  of  tubes. 
In  the  latter  case,  small  epithelial  sacs  penetrate  in  many  places  from 
the  wall  into  the  inner  layers  of  the  connective  tissue  of  the  cystic 
wall,  and  the  beginning  of  the  cystic  formation  can  be  often  discovered 
in  them  by  the  saccular  dilatations  of  the  blind,  or  closed,  ends  of  the 
tubes.  These  tubes  open  with  roundish  apertures  on  the  inner  surface 
of  the  w^alls  of  the  cyst,  and  are  often  blocked  up  by  a  tenacious 
gelatinous  plug.  This  is  made  the  more  evident  when  the  contents 
of  the  cyst  are  of  a  very  tenacious  character. 

The  secondary  cysts  of  the  ovarian  cystomata  resemble,  in  reference 
to  their  origin,  the  retention  cysts  in  other  organs.  According  to 
Boettcher,'  cystic  spaces  may  also  originate  in  the  following  manner: 
As  the  process  of  proliferation  goes  on  in  neighboring  glandular  tubes, 
the  walls  of  the  stroma  separating  them  become  perforated,  and  thus 
cut  off  many  glandular  pi-oliferations  that  are  blended  together,  a 
rather  large  epithelial  space  is  formed,  naturally  with  many  recesses. 
The  entire  developmental  act  of  a    proliferating  cystoma   proceeds 

'  Virchow's  Archiv,  49,  3  Heft,  s.  307. 


DERMOID    CYSTS.  707 

consequently  from  tlic  roundish,  or  tubular  epithelial  masses,  forming 
the  precursors  of  the  Graafian  follicles.  The  transformation  of  these 
epithelial  masses  may  either  begin  already  in  early  childhood,  when 
such  tubes  are  still  present  in  large  quantity,  or  they  are  new  formed 
in  consequence  of  a  pathological  process.  In  one,  or  in  many  of  these 
epithelial  groups,  the  epithelium  begins  to  proliferate ;  they  grow  on 
all  sides  into  ovarian  stroma,  combine  with  one  another  now  in  a  mani- 
fold way,  and  these  form  exceedingly  irregular-shaped  spaces,  and  ova 
are  never  met  with  in  these  formations.  A  secretion  soon  begins  in 
these  spaces,  and  in  this  way  they  are  expanded  into  cysts,  but  at  the 
same  time  numerous  glandular  and  papillary  proliferations  start  from 
the  epithelium  of  their  inner  surface,  and  they  are  constricted  to 
secondary  cysts,  or  fill  up  the  space  within  the  first  cyst  more  or  less. 
In  the  secondary  cysts  the  same  processes  are  carried  on,  and  so  it 
continues  in  uninterrupted  succession.  A  large  number  of  the  secon- 
dary cysts  coalesce  with  the  principal  cyst,  and  it  enlarges  as  well  in 
this  way  as  by  a  continuous  increase  of  its  contents.  Finally,  the 
retrogressive  or  other  pathological  processes  appear,  which  either 
terminate  the  growth  of  the  cystoma,  or  put  an  end  to  the  life  of  its 
possessor. 

Dermoid  Cysts. — In  regard  to  the  development  of  the  dermoid 
cystomata  Waldeyer  conjectures  that  it  may  take  place  as  follows, 
although  he  admits  that  his  views  are  not  based  upon  the  investiga- 
tion of  recent  specimens.  Each  ovarian  epithelial  cell,  he  thinks, 
may  become  an  ovular  cell,  and  each  ovular  cell  may  produce  all  pos- 
sible cellular  characters,  by  division ;  and  further,  the  corneal  layer  is 
the  first  product  of  segmentation.  Now  it  may  very  well  be  assumed 
that  the  epithelial  cells  of  the  ovary,  in  conformity  with  their  signifi- 
cance as  undeveloped  ovular  cells,  furnish,  in  their  multiplication  or 
division,  and  by  budding,  other  products,  and  in  fact  such  as  are  fur- 
ther advanced  in  the  direction  of  an  incomplete  embryonic  develop- 
ment than  they  themselves  are.  He  does  not  consequently  trace  the 
dermoid  cystomata  in  the  ovary  to  actual  foetal  remains,  but  to  pos- 
sibly foetal  inclosures,  nor  does  he  consider  them  as  results  of  per- 
verse ovarian  pregnancy.  He  assumes  a  mode  of  development  that 
runs  completely  parallel  to  the  course  of  development  of  the  myxoid 
cystomata,  but  in  which  the  new  formed  epithelial  cells  of  the  cys- 
toma assume  a  different  character;  in  fact,  they  are  epidermoidal  in 
structure. 

We  have  given  in  brief  Waldeyer's  views  as  to  the  development 
of  these  growths  in  the    ovary.     But  while  they  are  found  in  the 


768  TUMORS  OF  THE  OVARY. 

ovary  as  a  rule,  they  also  sometimes  develop  in  other  organs,  for 
which  circumstance  I  can  offer  no  explanation.  These  tumors,  when 
situated  in  the  ovary,  develop  very  slowly,  and  never  attain  to  the  size 
reached  by  the  cystomata.  They  are  lined  by  a  secreting  surface 
from  Avhich  the  fluid  contents  are  chiefly,  if  not  entirely,  derived,  and 
to  the  accumulation  of  the  secretion  is  due  the  increase  in  size.  This 
lining  membrane,  giving  the  character  to  the  tumor,  has  the  proper- 
ties of  skin-tissue,  with  sebaceous  and  hair  follicles,  and,  according  to 
some  observers,  even  sweat  glands  have  been  found.  The  fluid  con- 
tents of  these  cysts  are  of  a  greasy  consistency,  resembling  in  appear- 
ance pea-soup  or  gruel,  according  to  its  degree  of  density,  but  in 
which  can  be  seen  many  glistening  points  due  to  crystals  of  choleste- 
rine,  which  often  exist  in  large  quantities.  The  solid  contents  are 
teeth,  quantities  of  hair,  and  great  portions  of  bony  structures  in  which 
teeth  are  frequently  found  growing,  or  as  bony  scales  buried  in  the 
cyst-walls.  The  hair  is  generally  of  a  red  color,  growing  from  folli- 
cles in  the  lining  membrane,  and  is  frequently  found  of  greater  lengths 
rolled  up  into  balls. 

Dermoid  cysts  are  often  developed  in  early  childhood,  and  as  a  rule 
are  recognized  previous  to  the  period  of  life  when  the  cystomata  are 
more  common.  It  is  evident  that  these  cysts  are  much  more  liable  to 
take  on  inflammatory  action  than  any  other  growths  developed  in 
connection  with  the  ovary.  As  a  consequence  they  are  often  the  seat 
of  abscesses,  and,  becoming  encysted  by  a  cellulitis,  the  pus  finds  its 
way  generally  into  the  rectum,  and  less  frequently  into  the  vagina, 
and  by  this  means  a  channel  is  furnished  through  which  the  solid  con- 
tents are  also  evacuated.  A  few  cases  have  been  placed  on  record 
where  dermoid  cysts  have  emptied  into  the  bladder,  an  accident  which 
would  add  to  the  difficulty ;  yet  if  recognized  they  could,  by  removal 
of  their  contents  through  an  incision  in  the  base  of  the  bladder,  be  as 
advantageously  treated  as  in  any  other  locality. 


CYSTIC    TUMORS    OF    THE    OVARY.  769 


CHAPTER  XXXVIII. 

CYSTIC  TUMORS  OF  THE  OVARY  (Coxtknued). 

Unilocular  cysts  (monocystic,  oligocystic) — Multilocular  cysts  (compound,  prolige- 
rous,  polycystic) — Stages — Rapidity  of  development — Symptoms — Diagnosis. 

We  have  seen  in  the  preceding  chapter  that  these  tumors  may 
develop  apparently  as  a  single  cyst,  although  in  reality  this  never 
occurs  ;  and  that  on  account  of  the  number  of  cysts  of  all  sizes,  in  a 
common  sac,  they  sometimes  have  the  appearance  of  a  solid  mass. 
When  the  accumulation  is  contained  within  what  is  practically  a  single 
cyst,  the  condition  is  designated  by  different  writers  as  a  unilocular 
cyst,  a  monocystic,  or  oligocystic  tumor.  When  formed  of  many  cysts 
the  growth  has  been  termed  a  multilocular,  or  compound  cyst,  a  pro- 
ligerous  cyst,  or  a  polycystic  tumor.  I  shall  employ  the  term  uni- 
locular to  express  the  simple,  or  essentially  single  cyst,  and  multilocu- 
lar, for  the  compound,  or  tumor  formed  of  many  cysts. 

Dr.  Peaslee^  has  conveniently  divided  the  development  of  an  ova- 
rian tumor  in  the  following  manner: — 

"■  First  stage.  The  cyst  is  still  within  the  pelvis. 

"  Second  stage.  The  upper  extremity  of  the  tumor  has  risen  out  of 
the  pelvis,  and  is  extending  to  the  level  of  the  umbilicus. 

"  Third  stage,  includes  the  growth  upward  from  the  umbilicus  to 
the  epigastrium. 

"  Fourth  and  last  stage,  is  that  in  Avhich  the  growth  of  the  tumor 
is  such  as  to  increase  its  prominence  and  circumference  alone,  it 
having  risen  in  the  preceding  stage  to  its  highest  point. 

"  It  is  also  convenient  to  speak  of  the  middle  of  the  second  stage, 
the  tumor  reaching  halfway  from  the  symphysis  pubis  to  the  umbili- 
cus, and  the  middle  of  the  third  stage,  when  it  has  attained  to  the 
point  midway  from  the  umbilicus  to  the  ensiform  cartilage." 

The  interval  which  must  elapse  between  the  time  when  the  growth 
has  just  reached  a  size  to  be  detected  by  the  patient  and  when  the 
increasing  development  will  call  for  surgical  interference  must  vary 

'  Ovarian  Tumors,  their  Pathology,  Diagnosis,  and  Treatment,  etc.,  hy  E.  Ran- 
dolph Peaslee,  M.D.,  LL.D. 
49 


770  CYSTIC    TUMORS    OF    THE    OVARY- 

according  to  the  age  and  temperament  of  the  individual,  and  the 
character  of  the  growth. 

These  tumors  are  developed  with  most  rapidity  in  middle  life,  or 
about  the  time  for  the  final  cessation  of  the  menstrual  flow.  The 
rapidity  is  generally  in  proportion  to  the  number  of  cysts  composing 
the  mass.  The  average  time  for  a  multilocular  tumor  is  about  a  year, 
and  for  a  unilocular  from  a  year  and  a  half  to  two  years  after  it  has 
reached  a  sufficient  size  to  rise  out  of  the  pelvis,  and  the  patient  be- 
comes conscious  of  its  existence.  But  little  data  are  to  be  obtained 
as  to  the  average  length  of  time  of  the  first  stage  of  development ; 
but  it  is  always  a  long  one.  In  several  cases  under  my  observation, 
the  character  of  the  tumor  was  recognized  two  to  five  years  before 
the  patient  herself  became  aware  of  its  presence,  or  had  suffered 
from  any  inconvenience  beyond  what  was  attributed  to  a  supposed 
uterine  disease.  The  capacity  for  enduring  the  pain  and  discomfort 
of  a  tumor  varies  in  a  remarkable  manner  with  different  individuals  ; 
hence  the  time  at  which  it  becomes  imperative  to  interfere  also  varies. 
Instances  occur  where  the  presence  of  such  a  growth  in  the  pelvis 
will  establish  so  much  local  and  mental  irritation,  that  a  resort  to 
surgical  means  becomes  necessary  long  before  the  completion  of  the 
first  stage,  while  others  bear  the  most  advanced  degree  of  distension 
with  but  little  inconvenience. 

As  a  rule,  unless  some  cellulitis  is  established,  little  pain  or  incon- 
venience will  be  experienced  in  the  early  stage  of  development. 
Sometimes  the  symptoms  of  pregnancy  are  present,  as  nausea,  en- 
largement of  the  abdomen,  and  pain  in  the  breasts.  The  menstrual 
flow,  however,  is  rarely  absent,  and  if  changed  in  character  may 
become  more  painful  and  freer.  Constipation,  in  a  degree  natural 
to  the  sex,  is  almost  always  increased,  but  a  tendency  to  diarrhoea  may 
take  its  place.  Many  experience  a  greater  or  less  sense  of  pressure, 
or  distension,  while  standing,  somewhat  similar  to  what  is  felt  with 
retroversion. 

On  vaginal  examination,  a  fluctuating  mass  will  be  detected  on  one 
side  of  the  uterus,  or  filling  up  the  posterior  cul-de-sac,  the  uterus, 
as  a  rule,  lying  in  front  of  the  tumor,  and  ante  verted.  This  condi- 
tion may  be.  mistaken  for  a  cyst  of  the  broad  ligament,  for  a  hydro- 
salpinx, or  dropsy  of  the  Fallopian  tube,  for  extra-uterine  or  tubal 
pregnancy,  and  possibly  hematocele.  But  it  is  inexcusable  to  con- 
found it  with  retroversion,  a  fibroid  on  the  posterior  walls  of  the  uterus, 
or  with  any  stage  of  cellulitis.  Time  may  be  necessary  to  determine 
the  true  character,  if  the  tumor  is  situated  in  the  ligament,  tube,  or 


STAGES    OF    GROWTH.  771 

ovary.  As  long  as  it  remains  in  the  pelvis,  it  is  often  impossible  to 
make  a  diagnosis,  unless  some  of  the  fluid  is  obtained  for  examina- 
tion by  aspirating  through  the  vagina  ;  and  this  may  be  done  if  any 
urgent  reasons  are  apparent.  In  extra-uterine  pregnancy,  the  uterus 
is  always  found  enlarged,  and  the  cervix  soft,  while  often  symptoms 
of  pregnancy  will  also  exist,  and  more  or  less  constant  bloody  utei-ine 
discharge.  In  these  cases  the  uterus  is  generally  displaced  somewhat 
laterally,  and  the  mass  occupies  a  lower  position  at  the  side  of  the 
vagina,  and  is  in  closer  relation  with  the  uterus  itself,  than  an  ov^arian 
cyst  ever  is,  or  a  tubal  dropsy,  or  a  cyst  of  the  broad  ligament  at  so 
early  a  stage  of  development.  Moreover,  a  difference  exists  in  the 
shape  of  these  several  growths,  which  can  be  recognized  by  a  digital 
examination  per  rectum.  The  ovarian  cyst  is  almost  always  round 
and  uniform  in  shape ;  a  cyst  of  the  tube  is  irregular,  as  if  twiste<l 
upon  itself,  and  generally  largest  at  the  ovarian  end ;  and  in  tubal 
pregnancy  the  sac  can  be  felt  spreading  out  laterally  away  from  the 
uterus,  and  ballottement  can  be  frequently  gotten,  between  the  second 
and  third  month.  Or  by  letting  the  finger  rest  under  the  sac,  quietly 
in  the  rectum,  an  impulse  can  be  felt  transmitted  from  palpation  over 
the  abdominal  walls,  conveying  the  impression  that  a  somewhat  solid 
body  impinges  on  the  finger,  and  lies  free  in  the  fluid.  The  ovarian 
cyst  should  not  be  mistaken  for  hematocele,  for  if  the  history  should 
give  no  indication  of  the  condition,  the  finger  will  readily  recognize 
that  the  cul-de-sac  is  filled  as  it  would  be  by  a  fluid  settling  into  it. 
But  quite  a  different  impression  will  be  given  with  a  cyst  distended 
by  fluid,  which  preserves  its  own  special  outline,  Avbile  it  merely  rests 
in  this  locality. 

When  the  tumor  has  enlarged  sufficiently  to  rise  out  of  the  pelvis, 
the  second  stage  begins,  and  fluctuation  may  be  detected,  and  the 
mass  can  be  easily  moved  in  any  direction,  since  a  pedicle,  which  did 
not  exist  in  the  first  stage,  now  becomes  formed  by  the  traction  ex- 
erted. The  fundus  of  the  uterus  is  crowded  at  first  to  the  opposite 
side,  and  then  gradually  displaced  from  before  backward,  until  at 
length  the  whole  organ  is  retroverted,  and  lies  behind  the  tumor. 
This  change  in  the  position  of  the  uterus  almost  always  takes  place 
at  this  stage,  unless  pelvic  adhesions  have  been  formed.  By  means 
of  the  sound,  or  with  Sims's  elevator,  locked  at  the  proper  ano-le, 
it  is  easy  to  judge,  from  the  degree  of  mobility,  as  to  the  connections 
between  the  uterus  and  the  ovarian  tumor.  There  will  be  more  irri- 
tation of  the  bladder  excited  by  the  upward  traction  of  the  growth, 
and,  as  it  increases  in  size,  the  bladder  will  gradually  be  forced  under 


772  CYSTIC    TUMORS    OF    THE    OVARY. 

and  behind  tbe  tumor.     An  ovarian  tumor  may  be  mistaken  for  preg 
nancy  at  this  and  subsequent  stages,  if  the  examination  is  not  care- 
fully made. 

After  the  growth  has  reached  the  umbilicus,  the  third  stage  of 
development  is  begun.  The  small  intestines  are  crowded  behind  the 
tumor,  so  that  the  whole  anterior  face  of  the  abdomen  will  be  found 
dull  on  percussion,  except  along  the  course  of  the  colon,  and  the 
fluctuation  in  the  tumor  will  be  more  distinct. 

The  fourth  stage  is  marked  by  an  advance  in  the  growth,  and 
really  is  only  an  exaggeration  of  the  condition  already  existing ; 
there  is  more  discomfort,  and  usually  there  now  appears  the  first  evi- 
dence of  functional  derangement.  The  earliest  manifest  functional 
disturbance,  resulting  from  pressure,  is  generally  a  diminished  action 
of  the  kidneys.  Digestion  next  suifers,  with  loss  of  appetite,  irritability 
of  the  stomach,  and  either  diarrhoea  or  constipation.  The  proper 
degree  of  nutrition  is  no  longer  maintained,  the  woman  begins  to  lose 
flesh  from  about  her  neck  and  chest,  the  face  grows  thinner,  and  the 
cheek  bones  more  prominent.  The  whole  expression  becomes  so 
characteristic  as  to  have  been  termed  by  Mr.  Wells,  the  "  facies 
ovariana."  The  healthy  action  of  both  the  lungs  and  heart  is  early 
interfered  with,  and  as  the  circulation  becomes  more  and  more  ob- 
structed, the  veins  over  the  surface  of  the  abdomen  enlarge,  oedema 
occurs  in  the  lower  extremities,  and  sometimes  in  the  most  depending 
portions  of  the  abdominal  wall,  and  capillary  action  becomes  so  feeble 
that  the  skin  is  rendered  dry  and  inactive. 

The  time  has  now  arrived  when  relief  must  be  speedily  obtained,  and 
the  pressure  exerted  by  the  tumor  must  be  lessened  or  removed,  or  the 
patient  will  sink  rapidly  from  exhaustion,  and  ultimately  die  of  hectic. 

Pregnancy  has  formerly  been  mistaken  for  an  ovarian  tumor  at  the 
beginning  of  the  fourth  stage,  but  it  is  unnecessary  to  discuss  the 
differential  points,  since  the  mistake  should  never  occur  at  the  present 
day.  The'  two  may  coexist  in  different  stages  of  development,  and 
thus  might  render  it  difficult  for  us  to  make  a  positive  diagnosis  with- 
out resorting  to  measures  which  would  entail  the  risk  of  producing  a 
miscarriage.  Nevertheless,  with  proper  care  and  repeated  examina- 
tions, we  may  be  able  to  avoid  falling  into  serious  error.  When 
the  abdominal  cavity  becomes  distended  by  ascitic  fluid  after  the  in- 
testines have  been  bound  down  by  adhesions,  it  is  not  always  easy  to 
say  whether  pregnancy  or  ovarian  tumor  exists.  For  unlike  what  is 
characteristic  in  ordinary  ascites,  both  with  pregnancy  and  with 
ovarian  tumor  the  dulness  on  percussion  will  not  be  changed  by  shift- 


DIAGNOSIS.  773 

ing  the  position  of  the  patient,  since  the  intestines  are  unable  to  rise 
to  the  surface  of  the  fluid. 

A  cyst  of  the  broad  ligament,  if  greatly  enlarged,  might  be  readily 
mistaken  for  a  unilocular  ovarian  cyst,  but  an  examination  of  the  fluid, 
as  of  the  fluid  of  peritoneal  dropsy,  Avill  show  it  to  be  very  different 
from  that  found  in  an  ovarian  tumor.  The  same  may  be  stated  in 
regard  to  a  dermoid  cyst,  for  its  contents  bear  no  resemblance  to  those 
of  an  ovarian  tumor  ;  moreover,  a  tumor  of  this  kind  rarely  if  ever 
reaches  a  size  equal  to  that  attained  by  an  ovarian  growth  in  its  latter 
stages  of  development. 

There  are  many  other  conditions  which  have  been  mistaken  for 
ovarian  tumor,  but  the  subject  is  too  extended  a  one  to  be  treated  of 
here  at  greater  length,  especially,  since  I  hold  that  such  mistakes 
will  not  now  be  committed  by  any  one  who  has  had  experience 
sufficient  to  warrant  his  operating.  The  student  may  with  much 
profit  consult  Dr.  Peaslee's  valuable  work,  in  which  the  differential 
diaomosis  is  treated  of  in  a  most  exhaustive  manner.  It  contains  also 
a  description  of  renal  cysts,  cystic  growths  of  the  liver  and  omentum, 
and  other  rare  conditions  sometimes  mistaken  for  ovarian  tumors, 
but  so  seldom  met  with  as  to  justify  their  exclusion  from  this  work  in 
favor  of  more  practical  matter. 

A  fibro-cystic  tumor  of  the  uterus  is  the  only  growth  which,  after 
a  thorough  examination,  could  ever  be  mistaken  for  an  ovarian  tumor, 
and  it  is  even  held  that  this  may  be  diagnosed  by  an  examination  of 
the  contained  fluid.  This  is  true  in  many  cases,  but  there  are  ex- 
ceptions where  it  is  impossible  to  decide  until  after  an  exploratory 
incision  through  the  abdominal  walls.  Moreover,  I  have  myself  had 
several  cases,  in  which  both  an  ovarian  and  uterine  fibro-cyst  existed 
in  the  same  individual.  This  subject  will  be  again  referred  to  when 
treating  of  the  differential  diagnosis  between  the  two  conditions. 

No  examination  should  ever  be  deemed  completed  without  an  ex- 
ploration by  the  rectum.  The  following  unique  case  illustrates  the 
importance  of  this,  the  record  showing  that  without  a  rectal  examina- 
tion, it  would  have  been  impossible  to  determine  that  an  ovarian  tumor 
did  not  exist. 

Case  LVI. — Nov.  17,  1870,  an  unmarried  woman,  a  native  of  the 
United  States,  aged  36,  was  admitted  to  the  Woman's  Hospital,  with 
a  supposed  ovarian  tumor.  She  stated  that  ten  years  previous  to  admit- 
tance, she  detected  a  swelling  as  large  as  a  goose  egg,  in  the  right 
iliac  region,  her  attention  having  been  drawn  to  it  by  shooting  pains 
through  the  abdomen,  and  starting  from  this  point.  She  began  to 
suff'er  from  obstinate  constipation,  from  which  she  could  never  obtain 


774  CYSTIC    TUMORS    OF    THE    OVARY. 

entire  relief.  Otherwise,  she  had  experienced  little  inconvenience, 
except  from  a  feeling  of  distension  and  occasional  pain,  while  the  size 
of  the  tumor  increased  very  slowly.  Once  when  the  abdomen  was 
greatly  distended,  retention  of  urine  took  place  for  some  hours,  and 
the  catheter  had  to  be  used,  but  this  did  not  occur  again.  She  had 
been  suffering  for  some  time  with  pain  in  the  back  and  over  the  sacrum, 
which  was  increased  by  walking,  and  would  extend  to  the  thigh  after 
any  exercise.  The  right  leg  and  sometimes  both  feet  were  oedema- 
tous.  The  patient  on  admission  presented  a  very  cachectic  appearance, 
and  was  very  much  emaciated. 

The  abdomen  was  found  uniformly  enlarged  and  tympanitic  over  its 
whole  surface.  No  solid  mass  could  be  detected  by  palpation,  except 
a  slight  prominence  in  the  right  iliac  region,  which  was  thought  to 
be  the  fundus  of  the  uterus.  On  making  a  vaginal  examination, 
the  cervix  uteri  could  be  scarcely  reached,  situated  as  it  was  above 
the  pubis,  while  a  mass  was  felt  behind  in  the  cul-de-sac,  extending  to 
the  right,  apparently  an  ovarian  cyst.  But  from  a  digital  examination 
in  the  rectum,  it  was  made  evident  that  the  rectum  Avas  pushed  for- 
ward by  a  large,  soft,  fluctuating  tumor  behind  it,  which  filled  up  the 
hollow  of  the  sacrum  to  within  a  short  distance  of  the  anus.  It  was 
firmly  adherent  to  the  sacral  prominence 

December  2.  The  patient  was  placed  under  ether,  and  a  fine  trocar 
was  introduced  into  the  sac,  about  three  inches  beyond  the  anus,  by 
which  an  ounce  or  more  of  its  contents  was  aspirated  by  Dieulafoy's 
pump.  This  fluid  was  serous  in  character,  perfectly  clear  and  limpid, 
resembling  hysterical  urine.  It  contained  no  albumen,  and  the  micro- 
scope revealed  nothing  more  than  a  few  oil  globules,  which  had  beyond 
question  been  attached  to  the  instrument  before  its  introluction.    .     . 

Autopsy  nine  and  a  half  hours  after  death.  On  opening  the  abdo- 
men, the  colon  was  so  much  distended  as  to  fill  the  wdiole  cavity,  and 
reached  to  a  level  with  the  fourth  rib,  being  filled  with  flatus  and  feces. 
The  upper  border  of  the  uterus  was  two  inches  below  the  umbilicus, 
and  to  the  right  side.  The  bladder,  in  its  position  in  front  of  the 
uterus,  covered  it  except  a  small  portion  of  the  fundus.  A  cyst,  which 
contained  some  three  quarts  of  fluid,  was  found  behind  and  to  the  right 
of  the  rectum,  filling  completely  the  cavity  of  the  pelvis,  and  extended 
up  to  a  line  Avith  the  second  lumbar  vertebra.  The  left  ovary  and 
broad  ligament  Avei'e  spread  out  over  the  surface  of  the  rectum ;  both 
ureters  in  front  of  the  tumor,  the  left  being  much  dilated.  The 
i-ectum  was  greatly  constricted  in  its  upper  portion.  The  liver  was 
covered  by  the  colon.  There  was  chronic  cystitis.  The  kidneys 
were  found  diseased,  but  unfortunately  my  notes  of  the  case  do  not 
state  the  extent.  In  attempting  to  discover  the  attachments  of  the 
cyst  in  the  hollow  of  the  sacrum  it  was  ruptured.  The  sacrum  was 
removed,  and  a  spina  bifi<la  found,  the  three  lower  bones  of  the  sacrum 
bein"-  deficient  on  tlie  riglit  side.  A  funnel-shaped  opening  commu- 
nicated directly  with  the  spinal  canal,  from  which  projected  portions  of 
the  Cauda  equina  an  inch  or  more  in  length.  After  carefully  examin- 
ino-  this  opening  I  was  satisfied  that  the  cyst  had  been  cut  away  from 
its  margin.     Although  the  posterior  portions  of  the  bones  were  want- 


DIFFERENTIAL    DIAaNOSIS.  775 

ing,  no  external  ])ulginj:;  of  the  sac  could  take  place  posteriorly  in  con- 
sequence of  the  dense  ligamentous  structure  bridging  it  over.  Over 
the  posterior  surface  of  the  sac,  and  to  the  right  side,  a  network  of 
nerves  from  the  spiual  canal  extended  some  distance,  and  became  grad- 
ually lost. 

The  sacrum  was  dried  and  prepared  by  removing  the  ligamentous 
tissue,  which  stretched  across  the  posterior  wall,  where  the  bony  struc- 
ture was  wanting,  but  the  anterior  surface  was  left  entire.  On  exam- 
ining the  preparation  by  transmitted  light,  a  network  of  large  nerve 
filaments,  similar  to  those  on  the  sac,  could  be  seen  passing  down  di- 
rectly from  the  canal  and  spread  out  over  the  wdiole  surface.  These 
Avere  under  a  thin  membrane,  which  was  doubtless  a  continuation  of 
that  forming  the  posterior  wall  of  the  spinal  canal.  AVhere  the  sac 
had  been  removed,  these  nerves  could  be  seen  but  little  diminished  in 
size,  and  were  included  in  the  division  on  the  right  side,  throughout 
the  whole  extent.  The  boundary  of  the  canal,  at  the  point  where  the 
sac  had  been  removed,  as  indicated  by  the  rough  edge,  was  oval  in 
shape.  It  extended  from  the  upper  margin  of  the  second  sacral  fora- 
men on  the  right,  to  the  position  of  the  coccyx,  and  from  the  edges  of 
the  foramina  of  the  third  and  fourth  bones  on  the  left  side,  to  what 
would  have  been  the  width  of  the  sacrum  had  the  bone  been  fully  de- 
veloped. The  edges  of  the  sacral  bone  above,  and  of  those  on  the 
left  side,  were  gradually  rounded  off  so  as  to  form  the  funnel-shaped 
passage  already  described  as  leading  into  the  spinal  canal.  There 
was  a  deficiency  of  the  lower  spinal  process,  and  there  was  no  trace 
of  the  coccyx.  The  case  can  be  scarcely  called  one  of  true  spina 
bifida.  It  is  probable  that  the  bone  between  the  second  and  third 
sacral  foramina  was  not  developed,  and  an  opening  was  left  large 
enough  for  a  sac  to  protrude,  and  the  deficiency  afterwards  found  may 
have  resulted  from  absorption,  as  the  sac  gradually  increased  in  size. 

I  have  been  unable  to  find  any  case  on  record  where  a  deficiency 
existed  in  the  anterior  part  of  the  spinal  column.  This  case  presented 
a  feature  of  tolerance  to  pressure  of  the  cord  which  does  not  exist  in 
other  cases  of  spina  bifida  except  in  rare  instances,  and  then  only  to 
a  limited  extent.  Its  origin  being,  of  course,  congenital,  the  duration 
of  life  in  this  case  was  also  a  remai-kable  feature,  and  while  the  age 
was  given  as  but  35,  the  patient  presented  the  appearance  of  a  being 
fully  ten  years  older. 

(This  case  is  chiefly  of  interest  to  the  pathologist,  and  strictly  does  not  belong 
to  the  subject  under  consideration,  but  I  point  to  its  unique  character,  and  the 
fact  of  its  illustrating  how  important  for  differential  diagnosis  is  the  examination 
per  rectum,  as  my  apology  for  introducing  it  here.  It  was  presented  and  discussed 
at  a  meeting  of  the  New  York  Obstetrical  Society,  Jan.  3,  1871,  and  published  in 
the  American  Journal  of  Obstetrics,  Feb.  1871.  A  fair  although  too  small  a 
representation  of  the  appearance  of  the  sacrum  is  also  given  in  the  Journal.  I 
intended  to  have  a  large  drawing  made  of  this  bone,  but  unfortunately,  without 
my  sanction,  it  passed  into  the  hands  of  some  unknown  person,  who  possibly  de- 
sired to  study  at  greater  length  its  unique  peculiarities.  I  am  ignorant  of  its 
whereabouts,  but  hope  if  this  should  reach  the  eye  of  the  present  possessor,  he 
may  be  prompted  to  return  it.) 


776  CYSTIC    TUMOKS    OF    THE    OVARY. 

Differential  Diagnosis  between  certain  Fibrous  G-rozoths,  and 
Fibro-cysts  of  the  Uterus  and  Ovarian  Tumors. — When  the  uterus 
has  become  very  much  enlarged  from  the  growth  of  a  fibrous  tumor, 
a  certain  gelatinous  consistency  can  often  be  detected,  which  is  very 
deceptive  in  giving  the  impression  of  fluctuation.  But,  as  a  rule,  the 
uterus  will  not  be  found  uniformly  enlarged,  and  certain  hard  out- 
growths will  be  detected,  feeling  much  like  fibrous  nodules.  The 
history  will  often  furnish  the  best  basis  for  forming  a  diagnosis.  The 
growth  will  have  been  recognized  for  a  number  of  years.  A  tendency 
to  uterine  hemorrhage,  either  during  the  menstrual  nisus,  or  coming 
on  in  the  interval,  may  have  been  observed.  This  symptom,  however, 
cannot  be  relied  upon  alone,  since  bleeding  may  occur  with  an  ova- 
rian cyst,  and  is  not  always  attendant  upon  fibrous  tumor,  unless  the 
mucous  membrane  of  the  canal  is  encroached  upon.  The  uterine 
canal  will  generally  be  found  deeper  than  natural,  and  this  should  be 
received  as  suggestive  of  fibrous  tumor.  The  action  of  the  kidneys 
is  never  obstructed  by  fibrous  growths,  as  we  have  seen  is  always 
the  case  in  the  advanced  stages  of  a  rapidly-developing  ovarian  tumor. 
The  peculiar  expression  of  the  face,  so  characteristic  of  ovarian  tumor, 
is  never  found  with  fibrous  growth,  nor  is  there  the  same  loss  of  flesh, 
but  general  emaciation,  from  hectic,  accompanies  its  last  stages. 

When  a  fibrous  tumor  becomes  pedunculated,  as  sometimes  occurs, 
it  is  often  difficult  at  first  to  distinguish  it  from  a  partially-developed 
ovarian  tumor.  Time,  however,  will  make  the  difference  clear,  lono- 
before  the  growth  can  reach  a  size  calling  for  surgical  interference. 

Fibro-cystic  tumors  of  the  uterus  are  among  the  most  imjwrtant 
in  their  diagnostic  relation  to  ovarian  tumors.  It  has  been  but  a 
few  years  since  these  growths  were  first  recognized,  and  pointed  out  by 
Cruveilhier.  In  1871,  as  shown  by  Dr.  Charles  C.  Lee,^  now  surgeon 
to  the  Woman's  Hospital,  there  Avere  nineteen  cases  on  record,  where 
an  attempt  had  been  made  to  remove  these  growths,  through  mistaken 
diagnosis  of  ovarian  tumors;  nine  occurred  in  this  country,  and  ten 
abroad.  Only  a  small  proportion  of  such  mistakes,  I  believe,  are 
ever  published.  To  this  day  we  do  not  possess  any  perfectly  reliable 
means  for  determining  the  condition  under  all  circumstances,  and  our 
most  trustworthy  guides  are  a  highly-educated  touch,  and  well-trained 
powers  of  observation.  I  have,  in  former  years,  seen  an  unusual 
number  of  fibro-cystic  tumors  of  the  uterus,  from  my  being  so  long 
in  charge  of  the  Woman's  Hospital,  where  these  cases  were  often 

New  York  Medical  Journal,  Nov.  1871. 


DIFFERENTIAL    DIAGNOSIS.  777 

sent  when  the  physician  met  Avitli  difficulty  in  fonnin;^  a  diagnosis. 
But  now,  from  a  more  widespread  knowledge  of  these  growths, 
I  see  comparatively  few  cases,  yet  I  have  no  douht  that  they  are  far 
more  common  in  this  country  than  ahroad.  The  errors  which  some- 
times arise  in  differentiating  between  ovarian  tumor  and  fibro-cyst  of 
the  uterus  are  forcibly  illustrated  by  Case  XXXII,  page  562. 

Dr.  Peaslee  also  records  in  his  book  a  case  in  Avhich  both  he  and  I 
made  the  diagnosis  of  an  ovarian  tumor,  which  proved  at  the  opera- 
tion to  be  a  single  fibro-cyst  or  the  fundus  of  the  uterus.  It  was, 
however,  removed  with  but  little  difficulty,  and  the  woman  recovered. 
^ly  errors  of  diagnosis  in  this  line  are  summed  up  in  these  two  cases. 

It  is  well  to  pass  in  review  all  the  symptoms  which  have  been 
presented  as  connected  with  fibrous  tumors,  because  sometimes  they 
accompany  these  growths  before  they  develop  a  cystic  character.  In 
doubtful  cases  heretofore  it  has  been  regarded  as  good  practice  to 
make  an  explorative  incision  to  determine  the  character  of  the  tumor. 
When  the  parts  are  found  sufficiently  free  from  adhesions  so  that  the 
cyst-Avall  can  be  exposed,  the  true  character  of  the  tumor  can  gene- 
rally be  recognized  at  a  glance.  Nothing  is  more  characteristic  than 
the  dark  and  congested  appearance  of  a  fibro-cystic  tumor  of  the  uterus, 
so  strongly  in  contrast  with  the  light,  clear,  pearl-like  hue  of  most 
ovarian  cysts.  This  appearance,  however,  may  be  misleading,  since, 
in  some  multilocular  cysts  of  the  ovary,  when  the  several  cysts  are 
small  and  the  fluid  dense,  the  tumor  is  essentially  a  solid  one,  and 
when  its  circulation  is  obstructed  it  may  resemble  in  color  a  uterine 
fibro-cyst.  With  our  present  knowledge  there  are  no  better  means  of 
diagnosis,  in  obscure  cases,  than  the  examination  of  the  fluid  con- 
tents of  the  growths,  although  even  this  test  is  often  inconclusive. 


778  ABDOMIXAL    TUMORS. 


CHAPTER  XXXIX. 

ABDOMINAL  TUMORS. 
Contents  of  abdominal  tumors  and  ascitic  fluid  considered  in  relation  to  diagnosis. 

According  to  "Waldeyer,^  Eichwald  found  the  contents  of  ovarian 
cysts  to  contain  in  solution  chiefly  two  series  of  organic  substances, 
designated  by  him  as  belonging  to  the  mucin  and  albumen  series.  In 
the  mucin  series  he  classifies  mucin,  colloid  matter,  and  mucin-pep- 
tone.  In  the  albumen  series,  albumen,  paralbumen,  metalbumen,  and 
albumen-peptone. 

The  occurrence  of  paralbumen  and  metalbumen  is  of  especial  im- 
portance in  discrimination  between  ovarian  and  ascitic  fluid.  The 
first  especially  is  never  absent,  in  Waldeyer's  experience,  from  ovarian 
cystomata  ;  and  the  contents  of  the  Graffian  follicles  are  an  almost  pure 
solution  of  paralbumen.  The  sediment  of  the  cystic  contents  consists, 
according  to  him,  of  the  detritus  of  cells  of  diiferent  size  and  form, 
large  fatty  granules,  distended  cells,  in  a  state  of  paralbuminous, 
mucous,  and  colloid  degeneration,  with  many  well-preserved  cylindri- 
cal cells.  In  addition,  frequently  cholesterine  crystals,  blood  corpus- 
cles, pigment  scales,  and  pigment  granules  are  found. 

M.  Koeberl^  stated,^  at  the  meeting  of  the  ^Medical  Society  of 
Strasburg,  Xov.  15,  1875,  that  the  fluid  of  ovarian  cysts  contains 
some  albumen,  but  more  of  the  variety  called  paralbumen,  the  pre- 
cipitate from  which,  formed  by  nitric  acid,  was  soluble  in  acetic  acid. 
As  no  paralbumen,  but  albumen,  was  contained  in  the  fluid  from  a 
cyst  of  the  Fallopian  tube,  the  precipitate  formed  by  nitric  acid  was 
increased  by  acetic  acid.  The  contents  of  a  cyst  of  the  broad  liga- 
ment contain  salines,  and  seldom  albumen,  but  when  present  the  pre- 
cipitate formed  by  nitric  acid  becomes  soluble  in  an  excess  of  the  same 
acid. 

Mr.  J.  K.  Thornton,  of  London,  read  a  paper  April  20, 1876,  before 
the  Ilarveian  Society ,2  on  the  use   of  the  microscope  in  diagnosis  of 

'  Arcliiv  fiir  Gyn.iekol. 

2  The  Obstetrical  Journal  of  Great  Britain  and  Ireland,  April,  1877. 

'  Medical  Times  and  Gazette. 


CONTENTS    OF    TUMORS.  779 

ovarian  tumors,  and  in  connection  ■with  the  subject,  made  reference 
to  the  chemical  examination.  He  stated  that  he  phiced  the  greatest 
reliance  on  the  presence  of  paralbumen,  which  is  soluble  in  strong 
boiling  acetic  acid.  When  the  fluid  was  from  an  ovarian  cyst,  a 
coagulum  formed  on  heating,  which  was  either  entirely  dissolved,  or 
became  a  transparent  jelly  on  adding  an  equal  portion  of  strong  nitric 
acid,  and  continuing  the  application  of  heat.  If,  however,  the  coagu- 
lum became  only  partially  dissolved  or  gelatinized,  when  boiled  with 
an  excess  of  strong  acetic  acid,  the  fluid  was  in  all  probability  a  mixture 
of  both  ovarian  and  ascitic  fluid.  Bat  in  doubtful  cases,  as  an  indi- 
cation of  ovarian  fluid,  he  placed  much  value  on  the  presence  of  the 
ovarian  granule  of  Drysdale,  which  will  be  referred  to  hereafter. 

The  late  Dr.  Atlee  attached  much  importance  to  the  examination 
of  fluids  taken  from  abdominal  tumors  for  the  purpose  of  making  a 
diagnosis.  To  his  work^  I  would  refer  the  reader  for  more  extended 
details  than  can  be  given  here.  In  regard  to  the  diagnosis  of  one 
condition,  which  has  been  generally  found  by  others  most  difficult, 
his  experience  enables  him  to  express  very  positive  views,  viz.,  "In 
reviewing  the  foregoing  cases  of  fibro-cystic  tumors,  it  must  be  ap- 
parent that  I  regard  paracentesis  as  the  only  reliable  means  in 
certain  cases  to  be  adopted,  in  order  to  make  out  a  positive  diagnosis 
between  these  tumors  and  ovarian  cysts.  I  consider  the  fluid  removed 
from  the  fibro-cystic  uterine  tumor  to  be  blood,  minus  the  corpuscles, 
or  true  liquor  sanguinis  which  rapidly  coagulates  on  exposure  to  the 
atmosphere,  and  after  a  reasonable  time  separates  into  fibrin  and 
serum.  So  far  as  my  experience  goes,  I  have  met  with  no  other 
fluid  removed  from  the  abdominal  cavity  that  undergoes  such  changes, 
nor  have  I  met  with  any  other  form  of  tumor  that  furnishes  such 
a  fluid.  It  may,  therefore,  be  pronounced  not  only  diagnostic  but 
pathognomonic.  It  is  true  that  fluids  are  removed  from  the  general 
cavity  of  the  abdomen,  or  from  local  cysts  having  an  inflammatory 
orio^in,  in  which  are  formed  fibrinoid  substances.  But  the  entire  mass 
of  these  fluids  does  not  coagulate  on  exposure  to  the  air,  and  these 
fibrinoid  formations  usually  require  several  hours  for  their  production, 
and  appear  like  strings  suspended  in  a  large  quantity  of  fluid,  and 
very  different  from  the  clot  and  serum  above  referred  to.  It  is  also 
in  accordance  with  my  experience  that,  when  either  of  the  above  fluids 
is  removed  by  tapping,  Ave  must  exclude  the  idea  that  it  comes  from 
an  ovarian  cyst."     Dr.  T.  M.  Drysdale,  of  Philadelphia,  having  for 

1  General  and  DifFerential  Diagnosis  of  Ovarian  Tiimors,  etc.,  by  Wasliington 
L.  Atlee,  M.D.,  Pliila.  1873. 


780  ABDOMINAL    TUMORS. 

many  years  been  able  to  examine  the  contents  of  abdominal  tumors 
presenting  in  the  practice  of  Dr.  W.  L.  Atlee,  was  the  first  to  describe 
accurately  a  cell  which  he  calls  "  the  ovarian  granular  cell."  This 
he  claims  can  always  be  found,  by  the  aid  of  a  microscope,  in  the  fluid 
contained  in  the  ovarian  cysts.  Dr.  Drysdale's  views  are  fully  given 
in  Dr.  Atlee's  Avork,  and  his  essay  on  the  subject  will  be  found  in  the 
Transactions  of  the  American  jMedical  Association.  At  a  more  recent 
date  he  has  expressed  his  views  in  the  following  manner.^  "  It  is  not 
a  fsittj  degenerated  cell,  as  Dr.  Engelman  has  just  said,  but  a  cell 
characteristic  of  ovarian  fluid,  and  which  I  have  called  the  ovarian 
corpuscle,  or  cell.  It  is  an  albuminoid  body  containing  little  fatty 
particles  which  give  it  a  granular  appearance.  It  resembles  in  some 
particulars  many  other  granular  cells,  but  can  be  distinguished  from 
all  other  cells  found  in  the  abdominal  cavity.  I  have  examined  over 
1500  abdominal  fluids,  and  can  speak  with  regard  to  the  matter 
positively  and  conscientiously.  The  principal  test  I  employ  is  acetic 
acid.  If  the  cell  is  ovarian,  the  acid  changes  it  but  little,  perhaps 
renders  it  only  a  little  more  transparent.  But  if  it  is  a  white  blood 
cell,  a  lymph  corpuscle,  or  any  of  those  granular  cells  which  resemble 
them,  it  will  nearly  always  take  on  a  different  appearance  ;  the  cell 
almost  vanishing,  perhaps,  and  multiple  (2-5)  nuclei  appearing,  as 
in  the  pus  cell.  Then  if  the  cell  is  suspected  to  be  the  fatty  degene- 
rated or  Gluge's  cell,  ether  may  be  added,  by  which  the  fatty  matters 
will  be  dissolved  and  disappear.  If  no  fatty  degeneration  be  present, 
it  is  sufficient  to  add  acetic  acid." 

Dr.  Drysdale  can  speak  with  more  confidence  than  others.  I  be- 
lieve the  "  ovarian  corpuscle"  has  never  been  found  in  any  other 
tumor,  and  when  present  may  be  accepted  as  characteristic.  But  un- 
fortunately in  certain  cases,  where  the  physical  condition  may  leave 
the  most  expert  observer  in  doubt  as  to  the  true  character  of  the 
tumor,  this  corpuscle  is  sometimes  not  found  by  the  microscope.  In 
two  instances  of  doubt,  it  has  occurred  to  me  that  I  have  operated 
and  removed  ovarian  tumors  after  experts  were  unable,  from  an  ex- 
amination of  the  fluid,  to  give  me  the  slightest  information  in  regard 
to  the  character  of  the  tumor.  We  are  certainly  already  greatly 
indebted  to  Dr.  Drysdale,  but  I  hope  by  further  observation,  he 
may  yet  be  able  to  give  a  test,  which  can  be  relied  upon  under  all 
circumstances. 

It  will  rarely  happen  that  an  accumulation  of  fluid  in  the  abdomi- 

'  Trans.  Am.  Gynecological  Society,  vol.  i.  1877,  p.  195. 


DIFFERENTIAL    DIAGNOSIS, 


781 


nal  cavity  could  be  mistaken  for  an  ovarian  tumor.  But  an  ovarian 
tumor  might  exist  with,  and  be  hidden  by  an  ascites,  while  the  fluid 
may  have  resulted  from  the  peculiar  character  of  the  ovarian  tumor, 
or  it  may  have  been  caused  by  some  other  accidental  condition.  The 
accidental  causes  of  accumulation  may  be  due  to  disease  of  the  heart, 
kidneys,  or  liver,  having  no  connection  with  the  presence  of  the 
ovarian  tumor ;  while  the  tumor  itself  may,  in  consequence  of  its 
size,  impede  the  circulation  w^ith  the  same  effect  as  if  the  obstruction 
was  in  the  portal  system.     But 

the  most  important  point  of  all  ^'^S-  H^- 

is  to  ascertain,  by  an  examina- 
tion of  the  fluid,  if  a  certain 
papillary  groAvth  exist  which 
has  been  referred  to. 

This  growth  springs  from  the 
lining  membrane  of  the  smaller 
ovarian  cysts,  and,  as  shown  in 
Fig.  119,  begins  as  single 
papilla,  which  afterwards  coa- 
lesce. These  develop  rapidly, 
so  that  at  length  the  wall  of 
the  cyst  ruptures,  and  then 
retracts,  leaving  a  sprouting 
mass  projecting  far  into  the 
peritoneal  cavity,  as  shown  in 
Fig.  120. 

These  illustrations  Avere 
taken  from  drawings  of  a  tumor 
removed  by  me  in  1871,  and 
were  made  by  Dr.  James  B. 
Hunter,  at  that  time  one  of  my  assistants,  but  now  a  surgeon  to  the 
Woman's  Hospital. 

Either  as  a  consequence  of  the  presence  of  the  mass  itself,  or 
from  the  irritation  established  by  the  escape  of  the  fluid  also  con- 
tained in  these  cysts,  a  low  grade  of  peritonitis  becomes  established. 
This  growth  has  been  regarded  as  a  form  of  malignant  disease, 
and,  for  this  and  other  reasons  to  be  stated  hereafter,  it  is  urged 
that  such  a  tumor  should  be  removed  as  soon  as  its  character  be 
ascertained  by  an  examination  of  the  ascitic  fluid.  The  few  cases 
which  have  passed  under  my  observation  have  nearly  all  recovered,  as 
after  the  removal  of  any  other  ovarian  tumor.     The  diagnosis  in  all 


Papillary  growths  in  a  cyst. 


782 


ABDOMINAL    TUMORS. 


■^as  at  first  obscure  until  the  ascitic  fluid  had  been  removed.  This 
was  necessary  to  determine  the  character  of  the  mass  surrounded  by  the 
fluid,  I  was  not  at  that  time  familiar  with  the  microscopic  appearance 
to  be  described,  but  always  recognized  the  condition  by  the  presence 
of  blood  in  the  fluid,  which  increased  in  quantity  as  the  pressure  was 

Fis.  120. 


Papillary  projections  afcer  rupture  of  a  cyst. 

lessened  by  removing  the  accumulated  fluid  from  the  abdominal 
cavity.  With  every  case  where  this  condition  was  suspected,  prepa- 
rations for  the  operation  were  made  so  as  to  complete  the  removal  of 
the  mass  as  soon  as  possible.  I  have  never  regarded  the  condition  as 
malignant  m  character,  or  that  it  was  in  any  respect  more  than  a 
benign  growth,  accidental  to  ovarian  tumors,  and  accompanied  by  an 
ascitic  accumulation.  I  have,  however,  sometimes  observed  in  this 
supposed  malignant  disease,  that  patients  bore  badly  the  shock  of  the 
operation,  and  died  from  apparently  trivial  causes.  But  this  I  have 
always  attributed  to  the  additional  impairment  of  the  system  by  the 
accumulation  in  the  abdominal  cavity. 

Two  papers  of  great  practical  value,  on  "  The  Diagnosis  of  Malig- 
nant Tumors  of  the  Ovary  and  ]Malignant  Peritonitis,"  have  appeared,^ 
called  forth  by  certain  remarks  made  by  Mr.  Spencer  Wells.     These 

>  The  British  Medical  .Journal,  July  20,  1878,  by  James  Foulis,  M.D.,  Edinburgh  ; 
and  Sfptember  7,  1878,  by  J.  Knowsley  Thornton,  M.  B.,  C.  M. 


DIAGNOSIS.  783 

were  made  in  his  second  lecture  "  On  the  Diao;nosis  and  Sur^iical 
Treatment  of  Abdominal  Tumors,"  delivered  June  12,  1878,  in  the 
Royal  College  of  Surgeons  of  England,  and  were  as  follows: — "  Mr. 
Knowsley  Thornton  made  a  great  addition  to  our  knowledge,  in  point- 
ing out  that,  in  addition  to  these  cells  of  Drysdale,  which  are  common 
only  in  simple  or  innocent  ovarian  tumors,  in  malignant  tumors  you 
have  these  very  characteristic  groups  of  cells  of  different  sizes.  lie 
describes  them  as  large  numbers  of  characteristic  groups  of  large 
pear-shaped,  round,  or  oval  cells,  containing  a  granular  material  with 
one  or  several  large  clear  nuclei,  with  nucleoli,  and  a  number  of  trans- 
parent globules  or  vacuoles.  The  cells  composing  the  groups  are 
many  of  them  very  large,  but  the  great  variety  in  size  and  shape  is 
the  marked  feature  of  the  group.  If  you  will  bear  these  different 
forms  in  mind,  and  these  different  cells,  I  believe  you  will  find  that 
they  are  characteristic  and  of  great  value  in  the  examination  of  these 
fluids,  putting  us  on  our  guard  when  we  have  to  deal  with  tumors, 
doubtfully  malignant.  If  these  large  groups  of  cells  be  seen,  one 
may  be  pretty  certain  the  tumor  is  malignant  of  some  kind;  or  if  they 
be  found  in  fluid  removed  from  the  peritoneal  cavity,  probably  a  sort 
of  infecting  process  has  been  going  on  in  the  peritoneum,  from  rup- 
ture of  an  ovarian  cyst  of  a  malignant  character,  these  cells  may  have 
planted  themselves  upon  some  part  of  the  peritoneum  and  multiplied." 
Dr.  Foulis  took  exception  to  the  credit  thus  given  Mr.  Thornton, 
and  claimed  priority.  Mr.  Thornton  in  turn  justified  Mr.  Wells's 
statement,  saying  that  the  latter  had  been  familiar  with  his  views  be- 
fore Dr.  Foulis  had  first  placed  his  on  record.  It  is  made  evident, 
however,  from  these  statements,  that  equal  credit  is  due  to  each,  since 
each  began  his  investigations  within  a  few  days  of  the  other,  and  in 
ignorance  of  the  fact,  Dr.  Foulis  states :  "  If  the  microscopic  examina- 
tion of  the  deposit  in  the  ascitic  fluid  discovers  numerous  masses  of 
spouting  epithelium,  malignant  peritonitis  may  be  certainly  diagnosed. 
The  forms  of  these  spouting  masses  of  cells  are  extremely  various. 
Many  of  the  larger  masses  may  be  detected  with  the  naked  eye ;  the 
microscope,  however,  is  necessary  to  bring  most  of  them  in  view. 
But  whatever  their  form,  the  fact  remains  that  they  are  found  in  great 
numbers  in  ascitic  fluid  surrounding  malignant  ovarian  tumors,  and 
if  they  are  found  in  large  number  in  bloody  ascitic  fluids  we  may 
safely  conclude  that  one  or  many  villous  or  papillomatous  growths  are 
on  the  peritoneal  surface."  "The  finding  of  ovarian  granule  cells, 
and  a  few  specimens  of  small  masses  of  proliferating  cells  in  ascitic 
fluid  should  not  necessarily  prevent  the  attempt  to  remove  the  ovarian 


784  ABDOMINAL    TUMORS. 

tumor,  because,  as  the  result  of  experience,  we  have  found  that 
patients  may  remain  perfectly  well  from  whom  such  burst  tumors  have 
been  removed  ;  but  where  you  find  in  the  ascitic  fluid  a  great  number 
of  large  spouting  masses  of  cells,  many  of  which  are  visible  to  the 
naked  eye,  it  may  be  safely  concluded  that  the  peritoneum  is  seriously 
infected,  and  probably  the  ovarian  tumor  has  formed  such  adhesions 
with  neighboring  parts  as  will  prevent  its  entire  removal."  "The 
finding  of  spouting  masses  of  epithelium  within  the  ovarian  cysts  is 
not  of  much  practical  value,  as  such  tumors  are  often  removed  with- 
out risk  of  future  peritoneal  aifection." 

Mr.  Thornton  writes  :  "  I  believe  these  groups  to  be  of  two  kinds : 
the  one  consisting  of  masses  of  germinating  endothelium,  the  other  of 
masses  of  germinating  or  proliferating  cells,  derived  not  from  the  endo- 
thelium, but  from  the  ground  substance  of  the  peritoneum.  Various 
forms  will  be  seen,  some  looking  like  mere  clusters  of  lymph-coi'puscles 
(like  bunches  of  grapes),  others  like  more  or  less  flattened  endo- 
thelial plates  arranged  in  layers,  and  others  presenting  every  variety 
of  size  and  shape,  and  every  stage  of  growth.  It  is  these  latter  to 
which  I  attach  the  most  importance  as  indicating  malignant  disease, 
and  under  this  term  I  include  both  the  rapidly  growing  sarcomata  and 
carcinomota,  and  certain  peculiar  ovarian  papillomata.  I  have  great 
hopes  that  careful  study  will  enable  us  to  diagnosticate  by  these 
groups  not  only  the  presence  of  malignant,  as  differing  from  simple 
tumors,  but  also  the  special  forms  of  tumor.  I  would  say  here  that 
I  believe  the  presence  of  any  large  collection  of  ascitic  fluid  around 
an  abdominal  tumor  is  always  suggestive  of  malignancy,  but  whether 
its  presence  is  merely  due  to  irritation  of  the  peritoneum  by  rapid 
growth,  or  to  some  more  direct  infection,  I  think  is  at  present  un- 
certain." "These  seem  to  grow  slowly,  and  so  long  as  they  are  con- 
fined to  the  cyst  cavity  appear  quite  harmless,  but  cysts  containing 
them  are  very  prone  to  rupture,  the  first  result  of  such  rupture  being 
a  troublesome  ascites  from  constant  effusion  into  the  peritoneum  of 
ovarian  fluid,  and  its  consequences  already  mentioned  ;  and  Avhen  once 
they  grow  free  in  the  peritoneal  cavity,  they  assume  a  clinically 
malignant  aspect,  partly  from  the  readiness  with  which  they  contract 
adhesions,  rendering  the  removal  of  the  tumor  difficult  or  impossible, 
but  more  especially  by  an  actual  spreading  of  the  growths  over  the 
peritoneum,  the  proliferating  cells  rubbed  ofi"  in  the  movements  of  the 
patient  either  taking  fresh  root,  or,  as  my  observation  leads  me  to 
think,  causing  fresh  growths  at  points  where  they  settle  by  a  process 
of  auto-inoculation."     "  I  do  not  often  examine  the  lining  membranes 


CANCEROUS    NATURE    OF    CYSTS.  785 

of  the  cysts  now,  but  I  have  examined  quite  enough  to  make  me 
certain  that  the  form  of  papilloma  which  gives  rise  to  infection  is  com- 
paratively rare,  and  when  it  is  found,  it  is  commonly  found  in  every 
cyst  in  the  tumor,  and  often  fungating  through  from  one  cyst  to 
another,  or  to  the  external  surface."  "  I  still  maintain  that  the  find- 
ing of  the  cell-groups  in  the  cyst-fluid  is  the  all  important  point,  as  by 
prompt  operation  and  care  in  performing  it,  we  may  hope  to  prevent 
infection,  adhesions,  or  peritonitis.  And  I  have  seen  more  than  one 
case  giving  thoroughh^  convincing  proof  of  the  '  practical  value'  of 
the  discovery  of  these  cell-groups  while  still  confined  to  the  cyst,  and 
of  the  danger  of  neglecting  to  act  on  the  warning  given  by  their  dis- 
covery. Dr.  Foulis  still  attaches  importance  to  the  bloody  or  port  wine 
color  of  the  ascitic  fluid.  I  have  for  some  time  ceased  to  do  so,  as  at 
successive  tappings  of  the  same  cases,  I  have  found  the  peritoneal 
fluid  of  a  port  wine  color,  and  then  of  a  perfectly  clear  straw  color ; 
and  the  latter  has  contained  just  as  many  rankly  growing  cell-groups 
as  the  former."  "Reading  over  the  cases  operated  on  by  Mr.  Wells, 
Dr.  Keith,  and  Dr.  Atlee,  Avould  not  lead  me  to  agree  with  Dr. 
Foulis  as  to  '  so-called  ovarian  cancer'  being  common,  nor  would  my 
own  experience,  now  extending  to  six  or  seven  hundred  cases  of 
abdominal  tumor.  I  think,  considering  the  number  of  ovariotomies 
performed  and  published  by  the  leading  operators,  cancerous  or 
malignant  tumors  of  the  ovary  are  remarkably  rare,  and  the  cases  of 
recurrence  after  operation  still  more  so.  Compare  the  ovary  and 
breast  in  this  respect." 

I  scarcely  feel  that  an  apology  is  due  for  presenting  the  views  of 
these  two  observers  at  such  length.  The  subject  is  one  of  sufiicient 
importance  to  justify  the  attention  which  has  been  given  it,  and  from 
no  other  source  could  any  information  of  more  practical  value  be 
obtained. 

In  this  connection  Mr.  Keith's  views,  as  recently  expressed,^  are  of 
great  interest.  "  One's  pleasure  in  this  operation  is,  however,  greatly 
marred  by  the  frequency  with  which  malignant  disease  is  found  at 
the  operation,  or  reappears  soon  after  it,  upsetting  all  one's  calcula- 
tions. In  one-fourth  of  my  deaths,  the  tumors  were  malignant,  and, 
with  very  few  exceptions,  in  those  who  have  died  since  their  return 
home  after  ovaritomy,  some  cancerous  afibction  has  been  the  cause  of 
death.     Thus,  amongst  these,  five  young  and  healthy  looking  women 


'  Results  of  Ovariotomy  before  and  after   Antiseptics,  by  T.  Keith,   F.R.C.S. 
Edinburgh.     British  Medical  Journal,  Oct.  19,  1878. 
50 


786 


ABDOMINAL    TUMORS. 


have  left  me,  all  after  severe  operations,  the  pictures  of  health  and 
happiness,  and  have  died  within  a  short  time  of  peritoneal  cancer." 

This  is  certainly  a  remarkahle  experience,  and  confirms  the  state- 
ment which  has  been  advanced,  that  cancerous  affections  are  far  more 
common  in  old  settled  countries  than  in  our  own.  In  the  United 
States,  cancer  of  the  ovary,  in  any  form,  is  certainly  a  very  rare 
lesion.  During  the  past  eighteen  or  twenty  years  I  have  operated  for, 
or  have  witnessed  the  removal  of  at  least  one  hundred  ovarian  tumors, 
and  I  have  never  seen  a  case  of  cancer  in  connnection  with  one,  and 
of  papilloma  I  have  seen  only  five  instances.  Moreover,  I  have  never 
known  an  instance  where  cancer  has  appeared  at  any  time  after  the 
operation,  but  on  the  contrary,  having  recovered,  the  women  have  then 
entered  on  a  new  lease  of  life. 

To  obtain  the  fluid  for  examination  from  an  abdominal  tumor  by 
means  of  any  trocar  which  would  be  large  enough  for  the  flow  to 
take  place  through  it,  under  the  ordinary  pressure  of  the  atmosphere, 
would  often  be  attended  by  serious  consequences.    Several  fatal  cases 


Fig.  121. 


Emmet's  aspirator. 

have  been  reported  where  death  had  resulted  from  the  use  of  the 
ordinary  exploring  trocar.  Dr.  H.  F.  Walker,  of  New  York, 
suggested  and  first  used,  in  1870,  the  hypodermic  syringe  for  this 
purpose.  There  is  still,  however,  a  certain  amount  of  danger  attached 
even  to  so  sniall  a  puncture,  for  I  have  had  the  sac  become  inflamed 
after  employing  the  instrument;  yet  its  use  was  a  most  important 
conception.  The  small  size  of  the  hypodermic  syringe  enables  us 
to  obtain  only  a  very  small  quantity  at  a  time,  and  necessitates  its 
being  detatched   a  number  of  times,  and  thus  causes  much  incon- 


ASPIRATION    OF    CYSTS.  787 

venience,  and  sometimes  an  undesirable  amount  of  irritation.  At  one 
time  I  applied  Dieulafoy's  instrument  to  a  syringe  made  for  me  by  Mr. 
Stohlman,  attaching  to  it  the  stopcock  of  a  stomach  pump  (Fig.  121). 
By  this  arrangement  the  syringe  could  be  emptied  when  required, 
and  the  exhaust  again  made  without  removing  it.  At  Dr.  Walker's 
suffsestion  the  canula  was  made  as  small  in  diameter  as  that  of  a 
hypodermic  syringe,  and  this  made  an  admirable  instrument.  Yet, 
notwithstanding  the  evident  advantage  of  the  reduction  in  size  of  the 
canula,  already  six  deaths  have  been  reported  as  following  the  use  of 
the  aspirator  in  tapping  ovarian  cysts. ^ 

'  Report  of  the  Progress  of  Gynfecology  during  the  year  1875,  by  Paul  F.  Mund^, 
M.D.,  Am.  Journ.  Obstet.  April  1876  ;  and  Vaginal  Ovariotomy,  by  Dr.  Wm. 
Goodell,  Trans.  Am.  Gyn,  So.,  vol.  2,  p.  277. 


78^ 


TREATMENT  OF  OVARIAN  CYSTIC  TUMORS. 


CHAPTER    XL. 

TREATMENT  OF  OVAEIAN  CYSTIC  TUMORS. 

Internal  remedies — Surgical  treatment :  tapping;  injection  of  iodine;  drainage; 
vaginal  ovariotomy  ;  abdominal  ovariotomy. 

We  need  consider  only  briefly  tlie  treatment  of  ovarian  tumors  by 
internal  remedies.  Formerly  a  number  of  drugs  were  more  or  less 
noted  for  their  supposed  eflBcacy,  but  they  have  all  been  proved  to  be 
valueless.  The  inference  is,  that  in  cases  where  they  were  supposed 
to  be  serviceable,  there  Avas  an  error  in  diagnosis,  and  as  their  virtues 
were  held  to  be  due  to  their  action  on  the  kidneys,  it  becomes  very 
probable  that  ascites  was  often  mistaken  for  ovarian  tumor.  By  in- 
creasing the  action  of  the  skin,  kidneys,  and  bowels,  some  patients 
may,  perhaps,  be  temporarily  relieved  of  their  discomfort,  but  it  is 
well  established  that  no  remedy,  internally  administered,  can  produce 
the  slio;htest  change  in  the  contents  of  an  ovarian  tumor. 

The  various  surgical  measures  may  be  classed  as  follows : — 

Tapping. 

Injection  of  iodine. 
Drainage. 

Removal  of  tumor  through  the  vagina,  or  by  abdominal  in- 
cision. 

Tapping  should  be  regarded  as  palliative  only,  and  should  never 
be  resorted  to  except  for  making  a  diagnosis,  or  to  gain  time  when  the 
condition  of  the  patient  does  not  yet  admit  of  an  operation.  It  is  only 
applicable  to  single  cysts,  and  should  never  be  employed  in  the  multi- 
locular  variety.  Under  the  most  favorable  circumstances,  according 
to  Dr.  Peaslee,  one  death  in  every  twenty-five  or  thirty  cases  occurs 
from  the  first  tapping.  The  chief  dangers  arise  from  peritonitis, 
which  may  be  excited  by  the  escape  of  some  of  the  contents  of  the 
cyst  into,  the  peritoneal  cavity,  or  from  blood  poisoning,  the  result  of 
inflammation  of  the  lining  membrane  of  the  sac.  There  is  also  a 
certain  risk  from  hemorrhage  if  the  omentum,  which  is  often  adherent 
to  the  front  of  the  tumor  and  lower  than  usual,  is  wounded  ;  and  it  is 
even  possible  that  the  stomach  or  colon,  as  we  shall  show  hereafter, 


TAPPING.  789 

may  be  so  displaced  by  adhesions  as  to  be  exposed  to  the  trocar. 
The  larger  the  cyst  and  the  nearer  it  comes  to  being  to  a  single  one, 
the  less  irritating  will  the  fluid  be  to  the  peritoneum.  Repeated  tap- 
pings are  attended  -with  comparatively  little  danger  of  exciting  perito- 
nitis, for,  if  no  disturbance  arises  from  the  first  one,  the  inference  is 
fair  that  the  tumor  is  adherent  to  the  abdominal  walls.  While  danger 
from  inflammation  in  the  sac  always  exists,  it  is  also  less  liable  to 
occur  after  subse(iuent  tappings.  The  character  of  the  fluid  gene- 
rally changes  from  that  obtained  at  the  first  tapping,  losing  its  original 
transparency,  and  becoming  more  dense.  In  many  cases  tapping  may 
have  been  resorted  to  for  years  before  the  strength  of  the  patient 
succumbs  to  the  continued  drain.  Occasionally  single  cysts  do  not 
refill  after  having  been  tapped,  but,  as  a  rul*^,  when  this  occurs,  the 
probabilities  are  that  the  tumor  is  a  cyst  of  the  broad  ligament,  the 
fluid  from  which  is  bland  and  unirritating  to  the  peritoneum.  \Yhen 
the  contents  of  a  tumor  of  this  character  escapes  into  the  abdominal 
cavity,  through  the  puncture  in  the  cyst  wall,  it  will  be  absorbed. 
As  the  cyst  is  thus  kept  empty  it  rapidly  contracts,  until  at  length 
adhesions  form,  the  lining  membrane  is  changed  in  character,  secre- 
tion ceases,  and  the  tumor  disappears.  In  rare  instances  this  also 
may  occur  with  an  ovarian  cyst,  either  when  tapped  or  accidentally 
ruptured. 

The  operation  of  tapping  is  a  simple  one,  for  which  the  aspirator 
should  be  used,  or  a  trocar  longer  than  the  one  usually  employed  for 
ascites.  It  should  always  be  done  under  the  carbolic  spray,  and  care 
should  be  taken  to  prevent  the  entrance- of  air  into  the  sac.  Asa 
rule,  I  prefer  to  place  the  patient  on  a  narrow  couch,  and  tap  while 
she  lies  on  the  side.  With  all  other  considerations  equal,  the  median 
line,  midway  between  the  umbilicus  and  pubis,  is  the  safest  point  for 
making  the  puncture.  Yet  if  it  were  ascertained  that  the  main  cyst 
presented  to  either  side  of  the  median  line,  I  Avould  puncture  at  the 
most  advantageous  point,  out  of  reach  of  the  bladder,  colon,  and  stom- 
ach. Wherever  the  point  selected,  it  should  be  where  a  marked 
dulness  on  percussion  exists  and  extends  for  some  distance  around. 

Unless  a  very  large  trocar  be  used,  it  will  not  be  necessary  to  make 
an  incision  through  the  skin,  as  is  usually  done  on  emptying  the 
abdominal  cavity,  nor  will  a  bandage  be  required. 

The  requisite  support  and  pressure  must  be  kept  up  by  the  hands  of 
an  assistant,  placed  at  some  distance  from,  and  below  the  trocar.  He 
should  stand  behind  the  patient  and  carefully  steady  her  body  as  she 
is   rolled  over  to  empty  the  cyst.     The   operator  should  seize  the 


790  TREATMENT    OF    OVARIAN    CYSTIC    TUMORS. 

relaxed  tissues  about  the  trocar,  between  his  thumb  and  second  finger, 
and  at  inch  or  more  beyond  the  point  of  puncture.  This  is  done  to 
prevent  the  contents  of  the  cyst  from  escaping  into  the  abdominal 
cavity.  The  patient  is  to  be  then  turned  on  the  back,  and  the  trocar 
removed  while  the  tissues  are  still  grasped.  The  exit  of  the  instru- 
ment can  be  aided  by  placing  the  nail  of  the  index  finger,  which  is 
disengaged,  against  the  skin  at  the  edge  of  the  puncture.  A  small 
piece  of  adhesive  plaster  should  be  placed  over  the  puncture,  and  as 
the  relaxed  walls  are  held  together,  by  pressure  made  on  each  side 
with  the  flat  of  the  hand,  two  broad  strips  of  plaster  should  be  applied 
from  under  the  flank,  obliquely  across  the  abdomen,  to  the  neighbor- 
hood of  the  false  ribs  on  the  opposite  side.  Unless  it  be  determined 
to  inject  the  cyst,  the  use  of  Dieulafoy's  aspirator  is  far  preferable 
for  making  the  first  evacuation.  The  advantage  of  this  instrument  is 
that  it  afibrds  greater  immunity  from  evil  consequences  if  a  large 
viscus  or  bloodvessel  be  injured,  and  also  entails  less  danger  from 
peritonitis  and  inflammation  of  the  sac.  When  the  contents  of  an 
ovarian  tumor  are  too  dense  to  pass  through  the  largest  canula  of  the 
aspirator,  and  this  is  rare,  the  case  Avill  seldom  prov^e  a  good  one  for 
tapping.  We  must  not  suppose  the  tumor  to  be  a  solid  one,  should 
no  fluid  escape,  for  it  is  immediately  shown  not  to  be  solid  if  the 
canula  can  be  moved  freely  in  every  direction. 

While  the  tumor  is  yet  very  small,  and  probably  formed  by  a  single 
cyst  lying  in  Douglas's  cul-de-sac,  the  practice  of  tapping  through 
the  posterior  cul-de-sac  of  the  vagina  has  been  advocated. 

Dr.  Noeggeraty  has  treated  a  number  of  cases,  in  which  the  cysts 
were  small,  by  puncturing  them  from  the  vagina  with  the  hypodermic 
syringe  as  a  trocar,  and  has  been  so  well  satisfied  with  this  operation 
that  he  says  he  has  never  found  it  necessary  to  remove  these  cysts  by 
vaginal  ovariotomy,  an  operation  to  be  described  hereafter.  It  is 
held  that  while  these  cysts  are  so  small,  the  fluid  contained  in  them 
is  of  so  bland  a  character  as  to  be  unirritating  to  the  peritoneum,  and 
if  it  continues  to  escape  through  the  puncture,  success  will  be  the 
more  probable,  as  has  been  stated,  when  the  cyst  is  thus  kept  col- 
lapsed. With  other  cases,  as  soon  as  the  cyst  can  be  recognized  and 
at  the  earliest  stage  of  development,  while  its  Avails  are  thin  and  the 
fluid  unirritating.  Dr.  Noeggerath  ruptures  the  cyst  by  pressure  be- 
tween a  finger  in  the  vagina  and  the  hand  upon  the  abdominal  wall 
under  the  hope  that  it  may  not  refill. 

I  have  never  ruptured  such  a  cyst,  yet  if  the  diagnosis  can  be  made 

'  Transactions  of  the  Am.  Gync'eeological  See,  vol.  2,  p.  275. 


INJECTION    OF    CYSTS 


791 


out  early  enough,  I  do  not  believe  that  any  serious  consequences 
would  arise.  But  I  have  punctured  several  somewhat  larger  cysts 
with  a  trocar  from  the  vagina,  and  in  every  instance  more  or  less  cel- 
lulitis has  resulted.  This  might  have  destroyed  the  cysts,  but  I  am 
unable  to  determine  that,  for  the  cases  all  passed  from  under  my  obser- 
vation. Yet  should  one  of  these  cysts  fill  again  and  continue  to  develop 
it  would  be  most  probable  tliat  pelvic  adhesions,  as  a  result  of  the 
attempted  cure  by  rupture,  would  be  encountered  in  any  attempt  to 
remove  the  tumor. 

Injection  of  Iodine  iyito  Ovarian  Cysts. — Dr.  Alison,  of  Indiana, 
according  to  Dr.  Peaslee,  was  the  first  to  place  on  record  (1846)  the 
history  of  a  case  cured  by  injections  of  iodine,  but  to  Boinet  is  due 
the  credit  for  establishing  the  practice  as  a  suitable  one  under  certain 
circumstances. 

It  is  only  applicable  in  just  such  cases  as  we  have  pointed  out  as  proper 
for  tapping.  When  the  cyst  is  large  and  the  tumor  practically  uni- 
locular, and  free  from  adhesions,  the  careful  injection  of  iodine  into  it 
will  sometimes  be  followed  by  good  results.  The  iodine  is  not  injected 
for  the  purpose  of  producing  adhesive  inflammation  of  the  cyst  wall, 
for  this  would  lead  to  suppuration  and  blood  poisoning.  Its  effect  is 
in  some  way  to  arrest  the  secretion  of  the  cystic  fluid,  and  to  change 
the  character  of  the  lining  membrane,  after  Avhich  the  sac  shrivels 
aAvay  from  being  kept  no  longer  distended.  AVhen  iodine  is  injected 
into  a  pyogenic  sac,  after  the  pus  has  been  evacuated,  it  acts  bene- 
ficially by  changing  the  character  of  the  lining  membrane. 

Fig.  122. 


Thomas's  trocar. 


Before  injecting  the  iodine,  the  cyst  should  be  tapped  with  rather  a 
large  size  trocar,  of  sufficient  length  to  insure  the  instrument  against 
slipping  out  of  the  sac  as  it  becoirfes  emptied.  One  devised  by  Dr. 
T.  G.  Thomas  answers  admirably  for  this  purpose,  as  it  can  be  fixed 


792  TREATMENT    OF    OVARIAN    CYSTIC    TUMORS. 

within  the  sac  by  projecting  out,  like  the  ribs  of  an  umbrella,  a  number 
of  small  arms,  or  spurs,  near  the  end  of  the  canula  (Fig.  122).  A 
great  advantage  of  the  instrument  is  that  it  enables  the  walls  of  the 
cyst  at  the  puncture  to  be  held  in  close  contact  with  the  abdominal 
wall,  so  that  there  can  be  no  escape  of  fluid  into  the  peritoneal  cavity. 

After  the  cyst  has  been  emptied,  a  sufficient  quantity  of  warm 
water  should  be  injected  to  wash  oflF  any  ovarian  fluid  that  may  be 
adherent  to  the  lining  membrane.  This  is  done  by  attaching  to  the 
canula  a  short  piece  of  tubing  connecting  with  a  Davidson's  syringe. 
The  water  is  withdrawn  by  reversing  the  syringe.  It  is  of  the  great- 
est importance  to  exclude  air  from  the  cyst,  a  small  quantity  being 
sufficient  to  cause  inflammation  of  the  lining  membrane  of  the  sac, 
and  its  consequences.  The  operation,  therefore,  should  be  done  under 
carbolic  acid  or  some  other  antiseptic  spray.  Before  the  antiseptic 
method  was  in  vogue,  I  was  in  the  habit  of  applying  a  clamp  to  the 
rubber  tubing  to  prevent  the  entrance  of  air. 

The  syringe  is  to  be  filled  with  the  undiluted  tincture  of  iodine, 
U.  S.  P.,  and  thrown  directly  into  the  cavity  of  the  cyst.  After  de- 
taching the  syringe,  the  patient  must  be  turned  slowly  from  side  to 
side  and  placed  in  the  upright  position  for  a  few  moments,  so  that  the 
iodine  may  be  brought  in  contact  with  as  large  an  extent  of  surface  of 
the  sac  as  possible,  and  the  more  eflectually  this  is  done,  the  greater 
will  be  the  success  obtained. 

As  it  might  prove  a  source  of  irritation,  and  even  excite  peritonitis, 
should  any  quantity  of  the  iodine  escape  into  the  abdominal  cavity,  it 
must  be  carefully  withdrawn  from  the  cyst.  This  can  be  readily 
done  by  turning  the  patient  somewhat  over  on  the  face,  as  she  lies  on 
the  edge  of  the  bed,  so  as  to  bring  the  puncture  to  the  most  dependent 
part  of  the  body. 

If  the  canula  has  no  vents  or  slots  near  its  extremity  to  give  exit 
to  the  last  layer  of  the  fluid,  it  will  be  necessary  by  skillful  manipu- 
lation to  depress  its  inner  end  until  brought  in  contact  with  the  cyst 
wall ;  when,  if  it  is  properly  done,  not  only  will  all  the  iodine  come 
away,  but  with  it  any  air  which  may  have  accidentally  entered,  and 
the  walls  of  the  collapsed  cyst  will  fall  closely  together. 

In  the  usual  method  of  tapping,  when  the  cyst  is  to  be  injected,  a 
long  canula  of  sufficient  diameter  to  pass  a  large  size  flexible  male 
catheter  is  employed,  and  when  the  canula  is  withdrawn,  the  catheter 
is  left,  reaching  to  the  bottom  of  the  sac.  The  cyst  is  washed  out 
through  the  catheter,  and  the  iodine  injected  by  means  of  a  glass 
syringe,  the  nozzle  of  which  exactly  fits  the  mouth  of  the  catheter. 


INJECTION    OF    CYSTS.  793 

This  method,  however,  is  very  imperfect  in  comparison  with  that  in 
which  Thomas's  trocar  is  used. 

When  adhesions  exist  the  walls  of  the  cyst  will  not  be  brought  in 
contact,  nor  can  the  size  of  the  cavity  be  materially  diminished.  It 
cannot  be  determined  beforehand  whether  there  are  any  adhesions, 
but  if  some  are  found  no  evil  consequences  are  likely  to  follow  the 
injection  of  the  iodine,  for,  as  a  rule,  this  produces  less  disturbance 
than  a  simple  tapping. 

Mr.  Wells  has  recently  advocated^  the  following  practice  :  "  So  I 
think  we  may  lay  down,  as  almost  a  positive  rule,  that,  Avhen  we  can 
be  sure  that  the  cyst  is  a  single  cyst,  and  Ave  cannot  discover  any 
secondary  growths  in  the  cyst  wall  by  examination  by  either  the 
abdomen  or  the  vagina,  we  must  consider  it  a  duty  to  see  what  tapping 
will  do  for  a  patient  before  adopting  more  serious  measures.  I  think 
I  have  seen  quite  enough  now  to  warrant  me  to  endeavor  to  impress 
upon  surgeons  that,  if  the  cyst  be  a  single  cyst,  before  they  do  any- 
thing else,  they  should  see  what  can  be  gained  by  one  tapping.  If 
the  tapping  be  done  with  precaution,  the  risk  is  extremely  small ;  the 
patient  loses  nothing,  and  may  be  cured."  This  is  contrary  to  what 
has  been  heretofore  accepted,  but  as  it  is  advocated  by  a  careful 
observer,  one  who  has  had  a  greater  experience  than  any  other 
operator,  its  propriety  can  now  be  scarcely  questioned. 

I  would,  however,  recommend  that,  whenever  such  a  cyst  is  tapped, 
it  be  washed  out  and  iodine  injected  into  it,  in  order  to  lessen  the 
probability  of  its  refilling. 

All  authorities  agree  in  the  opinion  that  the  injection  of  iodine  is 
of  no  benefit,  but  is  often  hurtful,  Avhen  thrown  into  a  multilocular 
tumor.  My  experience  fully  confirms  this,  and  yet  the  result  in  the 
following  remarkable  case  may,  in  this  respect,  as  in  many  others,  be 
cited  as  an  exception  to  the  general  rule. 

Case  LVII. — Mrs.  Kate  D.,  aged  28,  was  admitted  to  the 
Woman's  Hospital,  Dec.  1,  1874.  She  had  given  birth  to  two  child- 
ren, and  had  miscarried  several  times.  About  eighteen  months  before 
admission,  she  first  noticed  a  movable  mass  on  the  right  side.  She 
became  pregnant  shortly  afterwards,  and  at  the  third  month  consulted 
a  physician  who  proposed  to  operate  notwithstanding  her  pregnancy. 
My  opinion  was  asked,  and  I  urged  that  she  should  go  to  full  term, 
and  hav^e  the  operation  afterwards  if  needed.  My  advice  was  followed, 
and  as  the  pregnancy  advanced,  the  tumor  Avas  crowded  up  and  over 
to  the  left  side,  but  Avithout  apparently  increasing  in  size.  In  fact, 
it  seemed  to  become  smaller  after  an  attack  of  vomiting,  shortly  before 

'  British  Medical  Journal,  June  29,  1S78. 


79-4  TREATMENT    OF    OVARIAN    CYSTIC    TUMORS. 

delivery,  when  she  threw  up  a  large  quantity  of  dark  coffee  colored 
fluid.  At  my  request  she  was  attended  by  Dr.  George  T.  Harrison ; 
the  labor  was  a  natural  one,  and  afterwards  the  tumor  dropped  back 
again  to  the  right  side.  Her  general  health  was  good,  and  she  was 
able  to  nurse  her  child,  but  the  growth  of  the  tumor  increased  so 
rapidly,  and  she  suffered  so  much  irritation  of  the  stomach,  that  Dr. 
Harrison  was  obliged  to  tap  her.  This  afforded  great  relief,  and  had 
the  effect  of  greatly  reducing  the  size  of  the  mass. 

At  the  date  of  her  admission  she  was  suffering  chiefly  from  dys- 
pepsia and  irritability  of  the  stomach . 

On  examination  a  globular  tumor  was  found  with  the  abdominal 
wall  drawn  apparently  tense  over  it.  Fluctuation  was  very  obscure, 
and  percussion  gave  dulness  over  all  of  the  abdomen,  except  just 
above  and  to  the  left  of  the  umbilicus.  This  resonant  portion  was 
supposed  to  correspond  to  the  transverse  colon,  which  it  was  even 
thought  could  be  seen  through  the  unusually  thin  abdominal  wall. 
From  the  vagina  no  portion  of  the  tumor  could  be  felt,  Avhile  the 
uterus  was  found  of  normal  size  and  retroverted,  but  movable. 

Dec.  3cZ.  I  began  the  operation  in  the  presence  of  Drs.  Peaslee, 
T.  G.  Thomas,  (jeorge  Harrison,  Bache  Emmet,  and  others  of  the 
Hospital  Staff. 

The  first  incision  was  some  five  inches  in  length,  and  was  carried 
down  carefully  to  the  tumor,  when  a  portion  of  what  was  supposed  to 
be  an  adherent  intestine  presented  itself.  Two  fingers  were  passed 
at  the  upper  angle  between  the  parieties  and  tumor,  from  which  point 
the  abdomen  was  laid  open  with  a  pair  of  scissors  nearly  to  the  ensi- 
form  cartilage,  the  tissues  being  divided  between  the  fingers  as  they 
were  advanced  for  protection.  The  incision  was  also  extended  to  the 
pubes.  Xo  adhesion  existed  to  the  abdominal  wall,  but  when  the 
flaps  were  turned  back,  a  condition  was  discovered  unique  and,  I  may 
add,  startling,  on  account  of  the  difficulties  presented.  The  stomach, 
colon,  and  omentum  were  all  adherent  to  the  surface  of  the  tumor  and 
below  the  line  of  the  umbilicus,  while  the  whole  upper  portion  of  the 
tumor  was  covered  by  peritoneum  placed  on  the  stretch  by  the  dis- 
placed organs.  The  tumor  was  inclosed  by  viscera  at  every  point 
within  reach,  except  just  above  the  bladder,  nearly  to  which  the 
omentum  extended.  The  empty  stomach  and  colon  lay  on  the  surface 
of  the  tumor,  resembling  wet  pathological  preparations,  and  were 
adherent  by  the  whole  surface  in  contact.  Notwithstanding  it  was 
suggested  that  the  tumor  might  be  removed  from  above,  and  by  getting 
behind  it,  as  these  were  apparently  the  only  adhesions,  I  closed  the 
incision  as  soon  as  possible. 

The  woman  was  placed  in  bed  and  began  to  vomit  violently,  appa- 
rently from  the  effects  of  the  ether.  Rupture  took  place  between  the 
stomach  arid  tumor,  and,  in  the  course  of  several  hours,  the  tumor 
was  entirely  emptied  of  its  contents. 

The  fluid  and  serai-fluid  substance  was  almost  sufficient  to  fill  two 
buckets,  and  were  of  various  colors,  showing  that  the  cyst  walls  rup- 
tured into  each  other,  until  at  length  the  tumor  became  essentially  a 


DRAINAGE.  795 

single  ca^^ty,  and  collapsed  for  the  time.  For  a  Aveclc  or  more  her 
condition  was  critical,  during  which  time  she  was  nourished  entirely 
by  the  rectum.  It  was  feared  that  if  food  were  introduced  into  the 
stomach,  it  would  pass  into  the  ovarian  sac,  and  set  up  inflammation 
and  blood  poisoning.. 

At  the  end  of  a  month  she  returned  home  with  the  tumor  already 
beginning  to  refill.  About  a  month  afterwards  I  advised  Dr.  Harri- 
son to  tap  her,  selecting  a  fluctuating  point  above  the  umbilicus  where 
it  was  dull  on  percussion,  and  where  the  stomach  should  have  been 
under  ordinary  circumstances.  I  iiad  called  his  attention  to  this 
peculiarity  at  the  time  of  the  operation,  and  noted  the  spot  as  being 
the  only  one  where  she  could  be  safely  tapped.  The  cyst  was 
tapped  at  this  point  with  Thomas's  trocar,  emptied  and  thoroughly 
washed  out  with  warm  water  previous  to  injecting  iodine.  As  the 
doctor  was  withdrawing  the  canula,  and  when  apparently  it  was  just 
out  of  the  cyst  wall,  a  jet  of  blood,  a  foot  or  more  in  height,  was 
shot  through  the  instrument.  Dr.  Whitwell,  then  house  surgeon  to 
the  Woman's  Hospital,  was  assisting  and  lifting  up  the  relaxed  ab- 
dominal wall  with  the  canula  in  his  grasp ;  pressure  was  made  on  all 
sides.  It  was  found  that  as  long  as  this  was  done  there  was  no  bleed- 
ing. The  pressure  was  maintained  by  compresses,  and,  after  removing 
the  canula,  an  abdominal  bandage  was  applied. 

The  woman  was  very  ill  for  two  months  afterwards,  suff'ering  from 
inflammation  of  the  sac,  with  more  or  less  blood  poisoning,  followed 
by  pelvic  cellulitis  and  phlegmasia  dolens  in  the  right  leg.  She  grad- 
ually recovered  her  health,  had  another  miscarriage,  and  then  a  child 
at  full  term.  Dr.  Harrison  attended  her  and  informed  me  that  he 
could  detect  no  trace  of  thickening  or  adhesions,  and  he  felt  satisfied 
that  these  had  been  absorbed,  and  that  the  stomach  and  transverse 
colon  had  returned  to  their  normal  position. 

At  the  time  of  writing  this  history,  after  an  elapse  of  four  years, 
she  is  in  excellent  health,  and  nothing  is  to  be  detected  beyond  some 
thickening  in  the  pelvis,  probably  the  remains  of  the  cellulitis  from 
which  she  suff"ered. 

I  do  not  cite  this  case  in  proof  solely  of  the  value  of  iodine  injec- 
tions, for  the  disappearance  of  the  cysts,  may  have  been  brought 
about  through  the  occlusion  at  the  time  of  the  injection,  of  the  main 
bloodvessel  by  which  they  were  nourished.  The  woman  certainly 
suffered  far  more,  and  her  life  Avas  in  greater  danger  than  would 
have  attended  the  ordinary  removal  of  an  ovarian  tumor. 

Treatment  of  Ovarian  Tumors  hy  Drainage. — The  occasional  effi- 
cacy of  this  plan  of  treatment  was  known  before  the  removal  of  an 
ovarian  tumor  had  become  an  accepted  operation. 

The  object  of  drainage  is  to  establish  a  permanent  opening  through 
which  the  sac  may  be  kept  empty  until  it  finally  disappears.  It  was 
customary  to  establish  the  opening  either  through  the  abdominal  walls, 
the  posterior  cul-de-sac  of  the  vagina,  or  the  rectum.     An  abdominal 


796  TREATMENT    OF    OVARIAN    CYSTIC    TUMORS. 

fistula,  except  for  some  special  reason,  would  now  rarely  be  made  for 
the  purpose  of  drainage,  since  no  benefit  could  be  looked  for  unless 
the  opening  were  placed  at  the  lowest  portion  of  the  cyst.  An  open- 
ing into  the  rectum  would  always  be  objectionable  in  consequence  of 
the  possible  passage  of  flatus  and  feces  into  the  cyst.  Whenever  the 
cyst  is  within  reach  it  would  be  best  to  establish  the  drainage  through 
the  posterior  cul-de-sac  of  the  vagina. 

Dr.  Noeggerath  has  reported'  several  successful  cases  treated  by 
drainage  through  the  vagina,  and  recommends  that  only  one  cyst 
should  be  punctured  at  a  time  as  it  presents,  in  consequence  of  the 
previous  one  having  contracted.  He  has  made  the  process  far  more 
efficacious  by  securing,  with  interrupted  sutures,  the  edges  of  the 
opening  in  the  sac  to  the  incision  through  the  wall  of  the  posterior 
cul-de-sac. 

With  our  present  knowledge  and  facility  for  the  removal  of  ovarian 
tumors,  this  operation  should  never  be  resorted  to  unless  the  tumor  is 
so  firmly  adherent  in  the  pelvis  as  to  render  it  very  dangerous  to 
attempt  to  separate  it  from  the  surrounding  tissues.  Under  these 
circumstances  the  treatment  by  drainage  is  admissible.  The  thorough 
washing  out  of  the  sac  is  important,  to  guard  against  blood-poisoning, 
and  to  lessen  the  amount  of  secretion  from  the  lining  membrane,  thus 
preventing  a  serious  drain  upon  the  patient's  strength.  The  hot 
water  employed  should,  from  time  to  time,  have  added-  to  it  proper 
quantities  of  tincture  of  iodine  or  carbolic  acid. 

Ovariotomy  ^  or  the  removal  of  an  Ovarian  Tumor  tlirough  the  Vagina, 
or  hy  Ahdominal  Incidon. — In  consequence  of  local  disturbance,  or 
on  account  of  some  reflex  irritation,  or  the  mental  condition  of  the 
patient,  it  may  become  advisable  to  remove  an  ovarian  tumor  at  a 
very  early  stage  of  development. 

While  yet  small,  as  has  been  pointed  out,  the  tumor  almost  always 
lies  in  Douglas's  cul-de-sac.  To  remove  it  an  incision  may  be  made 
in  tlie  septum,  the  tumor  drawn  into  the  vagina,  and  separated  from 
its  attachments. 

Dr.  T.  G.  Thomas,  in  Feb.  1870,  was  the  first  to  undertake  this 
operation  with  a  distinct  purpose,  and  the  result  was  successful.  The 
details  of  the  case  and  the  different  steps  of  the  operation  are  fully 
given  in  the  report  published  in  the  Amer.  Journ.  of  3Ied.  Sciences, 
April,  1870,  and  in  the  last  edition  of  his  work  on  the  diseases  of 
women. 

'  On  Ovariocentesis  Vaginalis.     Amer.  Jonrn.  of  Obstetrics,  May,  1869. 


VAGINAL    OVARIOTOMY.  797 

I  was  familiar  -with  the  fact  that  Dr.  J.  T.  Gilmore,  of  Mobile,  and 
Dr.  Clifton  E.  Wing,  of  Boston,  formerly  attached  to  the  Woman's 
Hospital,  had  each  a  successful  result  after  this  operation.  Dr.  Wm. 
Goodell,  of  Philadelphia,  has  placed  on  record*  a  similar  one,  per- 
formed by  himself,  and  cites,  in  addition  to  these,  one  by  Dr.  R. 
Davis,  of  Wilkesbarre,  Penna.,  and  another  by  Dr.  Robert  Battey,  of 
Georgia,  making  six  cases  of  cystic  disease  removed  by  vaginal 
ovariotomy,  operated  on  in  America,  and  all  terminating  favorably. 

Dr.  Goodell  also  places  on  record  the  fact  that  the  late  Dr.  Wash- 
ington Atlee,  in  February,  1857,  opened  into  an  accumulation  of 
puriform  fluid  filling  Douglas's  cul-de-sac,  no  clear  diagnosis  having 
been  made  of  the  case.  On  March  13  following,  the  incision  was  en- 
lar*red  and  the  mass  detached  from  its  adhesions  as  far  as  the  finger 
could  reach.  The  operation  was  then  suspended  with  the  hope  that 
nature  would  complete  the  removal  of  the  tumor.  Finally,  March  25, 
the  character  of  the  tumor  being  fully  determined,  the  mass  was 
drawn  down  into  the  vagina  and  removed  as  the  adhesions  were 
broken  up.  This  operation  was  not  based  on  any  fixed  plan  from  the 
beginning,  and  had  rather  an  accidental  termination,  therefore  it 
should  not  vitiate  Dr.  Thomas's  claims  to  priority. 

In  this  interesting  paper  Dr.  Goodell  gives  a  remarkable  case,  and, 
as  he  thinks,  a  unique  one,  where  an  ovarian  tumor  was  successfully 
removed  per  ♦rectum  by  Dr.  W.  W.  Shocks,  and  reported  in  the  Bost. 
Med.  Journ.,  October  16,  1875.  The  tumor  projected  through  the 
anus,  having  carried  the  anterior  wall  of  the  rectum  before  it.  The 
diagnosis  was  "aade  clear  on  recognizing  the  Fallopian  tube,  which 
could  be  felt  from  the  vagina  and  rolled  between  the  finger  and 
tumor.  The  tumor  was  removed  by  making  a  longitudinal  incision 
through  the  rectal  wall  covering  it. 

The  history  given  by  Dr.  Goodell  of  his  case,  and  of  the  one 
operated  on  by  Dr.  Wing,  clearly  shows  the  necessity  for  leaving 
the  wound  open  for  drainage,  and  for  washing  out  the  cavity,  as  a 
precaution  against  septic  poisoning.  Dr.  Thomas  secured  the  pedicle 
by  means  of  a  ligature,  which  was  cut  off  and  returned,  and  the 
wound  closed  by  interrupted  sutures.  The  Avoman  suffered  from  an 
attack  of  cellulitis,  which  was  attributed  to  carelessness  on  her  own 
part. 

The  range  for  this  operation  must  necessarily  be  very  limited,  and 
confined  chiefly  to  the  conditions  I  have  already  enumerated. 

'  A  Case  of  Vaginal  Ovariotomy.  Trans,  of  the  Gynjecological  Society,  vol.  ii. 
1877. 


798  TREATMENT    OF    OVAEIAX    CYSTIC    TUMORS. 

Ovariotomy  Inj  Abdominal  Incision. — To  trace  the  history  of  this 
operation  from  its  conception  to  its  present  state  of  development,  would 
he  an  undertaking  too  extensive  for  the  scope  of  any  work  so  general 
in  its  character  as  this.  A  review  alone  of  the  literature  would  he 
an  immense  task,  since  the  suhject  has  attracted  more  attention  within 
a  few  years  past  than  perhaps  any  other  within  the  range  of  surgery. 
Ths  late  Dr.  Peaslee  thoroughly  exhausted  it  in  his  classical  work  on 
Ovarian  Tumors,  but  within  the  past  six  years,  since  his  hook  was 
published,  more  has  been  written  in  reference  to  it  than  ever  before. 

Through  the  efforts  of  Dr.  Peaslee,  the  credit  is  now  accorded 
throughout  the  world  to  Dr.  Ephraim  McDowell,  of  Louisville,  Ky., 
as  being  "  the  father  of  ovariotomy,"  he  having  performed  the  opera- 
tion in  December,  1809,  long  antedating  all  other  operators.  To 
many  practitioners  in  this  country  and  in  Europe  we  are  indebted  for 
important  contributions  to  our  knowledge  of  ovariotomy. 

But  chiefly  to  Mr.  Spencer  Wells,  we  must  acknowledge  our  obliga- 
tion for  his  great  service  in  popularizing  the  operation,  and  making 
its  details  so  familiar  to  us.  The  world  is  largely  indebted  to  him  for 
his  valuable  teaching,  and  his  name  will  always  be  honored  where- 
ever  ovariotomy  is  known. 

To  the  remarkable  success  attained  by  Dr.  Charles  Clay,  of  Man- 
chester, England,  after  1842,  we  must  attribute  the  acceptance  of 
the  operation  by  the  profession  not  only  in  England  but  in  this 
country.  To  him  is  certainly  due  the  impulse  given  to  the  develop- 
ment of  the  operation  in  this  country  by  the  Atlee  brothers,  an  im- 
pulse so  favorable  that,  according  to  Dr.  Peaslee,  eighteen  American 
surgeons  had  performed  the  operation  previous  to  the  year  1850.  A 
more  accurate  knowledge  of  the  operation  was  obtained  by  the  publi- 
cation in  1855  of  Dr.  Atlee's  first  thirty  cases,  and  in  the  following 
year  a  prize  essay  on  ovariotomy,  was  written  by  Dr.  G.  N.  Lyman, 
of  Boston,  which  was  the  most  thorough  and  exhaustive  treatise  on 
the  subject  which  had  appeared  up  to  that  date.  After  1860  the 
number  of  operators  increased  so  rapidly,  that  I  cannot  do  more  than 
refer  in  a  general  way  to  the  most  important  contributions  on  the 
subject.  Before  entering  upon  a  detailed  account  of  the  operation,  a 
chapter  must  be  devoted  to  a  consideration  of  the  conditions  which 
may  complicate  it. 


COMPLICATIONS    IN    OVARIOTOMY.  799 


CHAPTER    XLI. 

CONDITIONS  WHICH  MAY  COMPLICATE  THE  OPERATION 
OF  OVARIOTOMY. 

Inflammation  of  tlie  sac — Peritonitis  and  ascites — Adhesions — Size  and  long  ex- 
istence of  the  tumor — Pregnancy — Cancer — Phthisis — Renal  disease — Uterine 
fibrous  tumors — Disease  of  the  other  ovary. 

The  conditions  which  may  complicate  the  operation  for  removing 
an  ovarian  tumor  are  : 

Inflammation  of  the  sac. 

Peritonitis  and  ascites. 

Adhesions. 

Size  and  long  existence  of  the  tumor. 

Pregnancy. 

Cancer — Phthisis — Diseases  of  the  kidneys. 

Uterine  fibrous  tumor. 

Disease  of  the  remaining  ovary. 
Inflammation  of  the  sac  although  of  vast  importance,  is  not  always 
recognized.  Symptoms  of  blood  poisoning  are  generally  present,  and 
the  appearance  of  the  patient  is  indicative  of  a  "  typhoid  condition.  " 
The  access  of  the  inflammation  may  or  may  not  be  ushered  in  by  a 
chill ;  the  pulse  increases  in  frequency,  and  is  attended  at  the  outset 
by  a  great  rise  in  the  temperature  of  the  body.  The  tongue  is  red, 
pointed,  and  dry  ;  the  teeth  are  often  covered  with  sordes  ;  there  is 
more  or  less  irritability  of  the  stomach  ;  and  there  are  stages  of 
moisture  of  the  skin,  or  sweating,  notwithstanding  the  elevation  of 
temperature.  The  abdomen  is  sometimes  tender  on  pressure,  and 
sometimes  entirely  free  from  pain.  As  the  case  advances,  the  mind 
becomes  more  or  less  afiected,  even  to  delirium.  At  length  the  kidneys 
being  overworked,  the  poison  is  no  longer  eliminated  from  the  blood, 
and  death  begins  at  the  nerve  centres  through  failure  of  their  nutri- 
tion. 

This  "  typhoid  condition"  was  formerly  generally  accepted  as  an 
omen  of  death.  It  was  thought  to  be  an  indication  of  irreparable  loss 
of  vital  force,  due  to  the  long  continued  irritation  exerted  by  the 
pressure  of  the  tumor.    Few  were  bold  enough  to  attempt  to  remove  a 


800  COMPLICATIONS    IN    OVARIOTOMY. 

tumor  from  a  woman  in  such  a  condition,  and  she  was  allowed  finally 
to  die  without  surgical  relief.  One  of  the  great  advances  which 
modern  gynaecology  has  made  is,  that  we  now  recognize  that  this  state, 
which  was  formerly  thought  to  he  ominous  of  death,  is  an  indication 
that  an  immediate  operation  is  called  for.  This  advance  could  have 
been  made  only  by  experience,  for  certainl;y  upon  every  d,  'priori 
ground  we  should  expect  any  patient  operated  on  in  such  a  condition 
to  sink  from  shock  before  the  operation  could  be  completed. 

It  is  true,  whatever  her  condition,  she  may  die  from  the  immediate 
effects  of  the  operation,  but  she  certainly  must  die,  and  at  an  early 
day,  if  the  cause  of  the  blood  poisoning  is  not  speedily  removed. 

This  condition  of  the  patient  is  sometimes  one  of  apparent  exhaus- 
tion only  ;  it  is  at  first  rather  an  indication  that  the  nerve  centres  are 
overwhelmed  by  the  presence  of  the  poison  in  the  blood,  and  not  that 
there  is  an  actual  loss  of  power  which  cannot  be  regained.  I  have 
seen  several  remarkable  instances  where  women  Avere  apparently 
snatched  suddenly,  as  it  were,  from  the  grasp  of  death  upon  removal 
of  the  inflamed  sac. 

The  following  case  will  not  only  illustrate  fully  this  part  of  the 
subject,  but  also  the  difficulties  sometimes  encountered  in  forming  a 
diagnosis. 

Case  LVIII.— Mrs.  W.,  aged  42,  consulted  me  Nov.  13,  1877. 
She  had  given  birth  to  two  children,  the  youngest  then  22  years  of 
age,  and  she  had  a  miscarriage  at  three  months,  ten  years  after  the 
birth  of  the  last  child.  After  having  menstruated  very  freely  for  many 
years,  she  became  irregular  the  year  before  admission,  and  supposed 
that  she  was  approaching  the  menopause. 

In  April,  1877,  she  noticed  for  the  first  time  an  elargement  on  the 
right  side.  This  was  recognized  by  her  physician  as  a  fibrous  tumor, 
and  she  was  placed  on  unusually  large  doses  of  ergot.  After  much 
suffering  she  was  seized  at  the  end  of  a  month  with  an  attack  of  peri- 
tonitis, which  confined  her  to  bed  for  three  months,  during  which  time 
the  abdomen  increased  rapidly  in  size.  Menstruation  continued  free, 
but  seldom  lasted  more  than  five  days.  She  was  placed  on  "  Cutter's 
diet,"  and  at  the  end  of  a  month  began  to  lose  flesh  rapidly. 

She  had  been  informed  by  her  physician,  a  month  before  consulting 
me,  that  she  had  a  fibrous  tumor,  and  was  incurable.  For  one  month 
she  had  had  a  continuous  flow. 

I  examined,  her  without  any  knowledge  of  the  diagnosis  made  by 
her  physician,  expressed  the  opinion,  and  placed  it  upon  record,  that 
she  had  an  ovarian  tumor,  the  nearly  solid  portion  of  which  was  just 
below  the  sternum,  and,  between  tins  mass  and  the  pubcs,  at  least  two 
large  cysts  with  unusually  thick  walls.  The  uterus  was  five  inches 
deep,  and  drawn  well  up  into  the  pelvis.     There  was  no  evidence  of 


SEPTICAEMIA.  801 

the  tumor  to  be  discovered  from  the  vagina,  but  the  remains  of  some 
thickening  of  a  former  cellulitis  were  detected  on  the  left  side  in,  as 
"was  supposed,  the  broad  ligament. 

Learning  then  for  the  first  time  the  opinion  which  had  been  given 
by  a  physician  of  experience,  and  for  whose  intelligence  and  skill  I 
have  the  highest  respect,  I  advised  her  to  consult  Dr.  Peaslee,  and 
without  giving  him  my  conclusions.  He  decided  that  it  Avas  an  ovarian 
tumor.  Dr.  T.  G.  Tliomas  was  also  consulted,  and  he  confirmed  the 
diagnosis. 

The  case  was  placed  in  my  charge  for  operation  as  soon  as  her  con- 
dition should  be  deemed  favorable.  Nov.  19,  I  withdrew,  by  means 
of  a  hypodermic  syringe,  some  of  the  fluid  from  a  cyst  on  the  right 
side,  Avhere  fluctuation  was  distinct  and  dulness  marked;  this  became 
solid  on  standing  a  few  moments.  I  had  already  taken  some  from  the 
opposite  side,  which,  remaining  liquid,  I  had  examined  with  the  micro- 
scope, when  it  was  pronounced  not  to  be  ovarian  fluid,  but  its  char- 
acter could  not  be  defined.  This  puncture  of  the  tumor  was  followed 
by  an  attack  of  supposed  peritonitis,  which  was  marked  by  an  increase 
of  pulse  and  temperature,  tenderness  on  pressure  along  the  sides  of 
the  abdomen,  and  irritability  of  the  stomach.  After  a  week  this 
attack  seemed  to  subdside,  but  her  general  condition  did  not  improve, 
while  the  size  of  the  tumor  increased  rapidly. 

Dec.  8.  I  regarded  her  condition  as  so  critical  that  I  called  Dr. 
Peaslee  in  consultation,  and  it  was  decided  to  tap  her  immediately. 
This  I  did,  the  patient  lying  on  the  side,  and  drew  ofi'  23  pints  of  fluid, 
emptying  both  cysts  by  pressing  the  end  of  the  canula  through  the 
septum  between  the  two  after  the  first  cyst  had  been  emptied.  In 
doing  this  I  felt  certain  that  I  fully  appreciated  the  relative  position 
of  the  cysts,  yet  the  practice  cannot  be  recommended  as  being  free 
from  danger.  When  both  cysts  had  been  emptied,  there  remained 
the  hard  mass  above,  which  could  be  felt  through  the  abdominal  wall, 
passing  down  behind  as  a  solid  body  into  the  pelvis.  She  was  too 
much  exhausted  afterwards  to  admit  of  a  more  thorough  examination. 
Dr.  Peaslee  took  for  examination  a  portion  of  this  fluid,  which  to  the 
eye  and  by  gas  light  had  the  appearance  of  ovarian  fluid.  But  the 
result  of  his  examination,  coupled  with  the  character  of  the  tumor 
after  tapping,  unsettled  his  diagnosis,  and  he  was  unable  to  decide  as 
to  its  nature.  I  sent  some  of  the  fluid  to  Dr.  James  B.  Hunter,  of 
the  Woman's  Hospital,  who  pronounced  it  ovarian,  but  stated  that  he 
found  very  few  ovarian  corpuscles.  Another  expert  who  examined 
the  fluid  for  me  stated  positively  that  it  was  not  ovarian.  Dr.  Drys- 
dale,  of  Philadelphia,  had  very  kindly  offered,  some  time  before,  to 
make  an  examination  for  me  in  such  a  case,  and  as  1  had  expressed  a 
doubt  as  to  the  uniform  reliability  of  the  microscopic  test,  I  sent  some 
of  this  fluid  to  him,  stating  that  there  was  a  diflerence  of  opinion  in 
regard  to  the  tumor,  whether  a  fibro-cystic  tumor  of  the  uterus  or  ovary. 
In  justice  to  the  doctor,  I  must  state  that  he  found  the  quantity  too 
small  for  a  complete  examination.  He  wrote  that,  '"  if  it  were  not  for 
51 


802  COMPLICATIONS    IN    OVARIOTOMY. 

the  microscopic  appearance  of  the  fluid,  he  would  pronounce  it  ova- 
rian." 

The  tapping  gave  only  temporary  relief,  inflammation  of  the  sac 
occurred,  she  began  to  run  down  rapidly,  and  the  symptoms  of 
septicgemia  presented  themselves.  Dr.  JPeaslee  saw  her  again  in  con- 
sultation, 

21st.  In  consequence  of  the  irritable  condition  of  her  stomach,  in 
which  for  several  days  she  had  not  retained  even  the  water  from  a 
piece  of  melted  ice,  and  her  general  blood  poisoning,  it  was  decided 
to  operate  within  twenty-four  hours,  under  the  belief  that  a  longer 
delay  would  prove  fatal.  She  and  her  friends  were  informed  of  the 
difference  of  opinion,  and  of  the  danger  of  her  condition,  but  that  an 
attempt  must  be  made  to  remove  the  tumor,  if  possible. 

On  the  folloAving  day  I  operated,  with  Drs.  Peaslee,  Bache  Emmet, 
and  E.  C.  Dudley  to  assist  me,  and  Dr.  Harrison  to  administer  the 
ether.  Dr.  R.  F.  Weir  kindly  directed  the  spray  apparatus,  and 
took  charge  of  all  details,  that  the  operation  might  be  conducted  under 
his  direction  in  strict  accordance  with  the  antiseptic  method.  Dr. 
Crane,  of  Richfield  Springs,  and  Dr.  A.  E.  M.  Purdy,  wefe  also 
present. 

The  patient  had  received  no  nourishment  for  several  days  except 
by  the  rectum;  her  pulse  was  126,  and  temperature  103°  just  previous 
to  the  operation. 

On  cutting  down  upon  the  tumor  I  found  old,  firm  adhesions  between 
the  tumor  and  abdominal  wall,  and  I  was  obliged  to  tap  immediately. 
Nearly  two  basin-fuls  of  fetid  pus  were  evacuated  from  the  large 
cysts,  the  communication  between  the  two  remaining  since  the  lasttap- 
pmg,  and  but  for  the  carbolic  spray,  the  odor  would  have  been  intol- 
erable. The  tumor  was  firmly  adherent  to  the  entire  abdominal  wall, 
from  the  stomach  to  the  pubes,  and  above  to  the  omentum.  The 
small  intestines  were  intensely  congested  from  peritonitis,  and  the 
parietal  peritoneum  was  of  the  same  color,  and  inflamed  behind,  where 
it  was  not  adherent  to  the  tumor. 

At  the  end  of  an  hour  and  a  half  I  succeeded  in  removing  the  tumor, 
the  upper  part  of  which  was  formed  of  many  small  cysts  which  gave 
the  impression  of  a  solid  mass.  A  remarkable  feature  was  the  growth 
and  formation  of  a  large  cyst  from  below,  leaving  the  multilocular 
portion,  contrary  to  the  rule.  The  pedicle  was  ligated,  dropped  back 
into  the  abdominal  cavity,  and  the  external  incision  closed  with  but 
little  delay.  She  was  placed  under  the  immediate  care  of  Dr.  Bache 
Emmet,  and,  although  greatly  reduced  from  her  general  condition,  made 
a  good  recovery. 

I  have  felt  it  important  to  enter  into  the  details  of  this  case,  for  I 
thus  show  more  clearly  than  by  a  simple  statement,  that  cases  are  met 
with  in  practice,  where  sometimes  no  amount  of  experience  enables  us 
to  decide  from  a  physical  examination,  as  to  the  true  character  of 
these  tumors  ;  and  further,  that  even  in  the  hands  of  the  most  prac- 
tised experts,  the  microscope  cannot  always  be  depended  upon. 

There  are  other  circumstances  connected  with   this   case    of  the 


PERITONITIS.  803 

greatest  importance,  and  although  not  bearing  on  the  subject  under 
consideration,  more  than  the  above  remarks  regarding  the  diagnosis, 
they  may  as  Avell  be  cited  in  completing  the  history  of  the  operation. 

The  adhesions  were  separated  over  a  much  larger  extent  than  usual, 
but  the  spray  seemed  to  control  the  oozing,  for  in  instances  where 
they  liave  been  much  less,  and  where  the  spray  was  not  used,  I  have 
been  delayed  by  the  oozing  for  an  hour  or  more  longer  than  in  this 
case.  It  was  noted  by  all  present  that  the  effect  of  the  carbolic  spray 
was  to  cause  rapid  capillary  contraction,  and  that  under  it  the  amount 
of  oozing  was  insignificant.  The  parts  gradually  returned  to  a  natural 
color,  and  at  the  termination  of  the  operation  all  appearance  of  the 
peritonitis  had  disappeared.  The  time  thus  gained  in  this  case  doubt- 
less aided  the  patient's  recovery. 

But  the  most  interesting  circumstance  in  connection  with  the  use 
of  the  spray  was  the  disappearance  of  the  septicsemia.  At  the  be- 
ginning of  the  operation  the  patient  was  suff"ering  from  symptoms  of 
profound  blood-poisoning,  and  particularly  from  irritability  of  the 
stomach.  She  awoke  from  the  effects  of  the  ether  as  from  a  natural 
sleep,  without  nausea  or  any  other  evidence  of  blood-poisoning. 

When  treating  of  fibrous  tumors  I  called  attention  to  the  probable 
eff"ect  of  large  doses  of  ergot  in  producing  peritonitis.  The  history 
of  the  case  just  given  resembles  very  closely  several  others  which 
have  passed  under  my  observation,  in  which,  through  error  in  diag- 
nosis, large  doses  of  ergot  were  given,  and  were  followed  by  perito- 
nitis, which,  I  cannot  but  feel,  was  due  to  the  drug.  If  this  be  true, 
it  can  only  be  explained  by  the  suppositon  that  the  ergot  acted  as  a 
local  irritant,  producing  intense  congestion  in  the  pelvic  vessels,  and 
as  there  was  no  organ  or  condition  upon  which  it  could  exert  a  salu- 
tary effect,  inflammation  resulted.  I  am  satisfied,  from  observation, 
that  an  immense  deal  of  harm  is  done  by  the  injudicious  use  of  ergot, 
even  when  the  drug  is  indicated,  and  particularly  in  the  administra- 
tion of  unnecessarily  large  doses. 

Peritonitis  and  Ascites. — The  existence  of  peritonitis  does  not 
necessarily  contraindicate  an  early  removal  of  the  tumor.  On  the  con- 
trary, as  the  presence  of  the  tumor  is  often  the  cause  of  irritation,  peri- 
tonitis may  be  an  indication  for  an  immediate  operation.  In  chronic 
peritonitis,  where  the  peritoneum  has  been  long  subjected  to  the  pressure 
of  the  tumor,  its  character  is  so  materially  altered,  and  it  is  so  little 
responsive  to  irritation  that,  unless  extensive  adhesions  exist,  the 
patient's  chances  for  recovery  are  often  better  after  the  removal  of 
the  tumor  than  if  the  peritoneum  were  in  a  perfectly  healthy  condi- 
tion. 

After  rupture  of  a  cyst  in  a  multilocular  tumor  the  operation  should 


804  COMPLICATIONS    IN    OVARIOTOMY. 

not  be  delayed  longer  than  necessary,  to  insure  a  reaction  from  the 
shock.  It  is  good  practice,  under  these  circumstances,  to  open  the 
abdomen  befoi-e  inflammation  can  set  in,  and  remove  the  tumor  and 
the  contents  of  the  cyst  which  had  ruptured  and  discharged  into  the 
peritoneal  cavity.  This  is  an  accident  which  almost  always  termi- 
nates fatally,  from  peritonitis,  if  the  contents  of  a  cyst  be  left  in  the 
cavity.  It  is  essentially  a  foreign  body  Avhich  cannot  be  absorbed, 
and,  as  such,  excites  peritonitis  and  ascites. 

Dr.  Peaslee  in  his  work  states  (page  75)  that  he  had  seen  five 
cases  of  spontaneous  rupture  of  polycysts,  and  four  of  these  had  died 
of  peritonitis  within  five  days  after  the  accident.  "  The  remaining 
one  barely  recovered,  and  the  tumor  was  successfully  removed  by 
ovariotomy  about  a  year  afterwards  by  Dr.  T.  A.  Emmet,  of  the  New 
York  State  Woman's  Hospital."  This  remarkable  case  was  reported 
by  her  physician,  Dr.  S.  A.  Raborg,^  through  Avhose  recommendation 
she  Avent  to  the  Woman's  Hospital.  The  following  constitute  the 
essential  features  of  the  case:— 

Case  LIX. — Mrs.  L.,  aged  33,  was  attended  by  Dr.  Raborg  in  her 
third  confinement  Jan.  14,  1868.  Several  months  afterwards  she 
noticed  an  enlargement,  which  the  doctor  recognized,  in  September  of 
that  year,  as  a  round  and  hard  ovarian  tumor  on  the  left  side,  which 
diagnosis  was  confirmed  by  Dr.  Peaslee.  On  the  following  October 
11th  Dr.  Raborg  was  sent  for  in  great  haste  to  see  the  patient,  Avho 
had  been  out  riding,  and  was  then  in  a  state  of  collapse.  This  Avas 
doubtless  due  to  the  rupture  of  a  cyst.  The  kidneys  were  very  active 
for  several  days,  but  the  peritoneum  began  to  fill,  and  four  months 
afterwards  she  was  tapped  by  Dr.  T.  C.  Finnell.  Present,  Drs. 
Raborg,  Peaslee,  Bigelow  of  Ga.,  the  house  stafi",  and  others.  The 
girth  of  body  at  the  umbilicus  was  thirty-seven  and  a  half  inches. 
She  was  admitted  to  the  hospital  Sept.  28,  1869. 

Oct.  25.  An  incision  was  made  extending  from  the  umbilicus  to 
the  symphysis  pubis.  The  abdominal  walls  were  very  thin,  and  a 
considerable  quantity  of  fluid  escaped  from  the  peritoneal  cavity,  evi- 
dently having  come  from  a  cyst  which  ruptured  Oct.  11,  over  one 
year  previous.  There  was  a  chronic  peritonitis,  but  no  adhesion  to 
the  abdominal  walls,  only  one  to  the  omentum.  A  Wells'  trocar  was 
plunged  into  the  tumor,  but  no  fluid  escaped  until  the  colloid  or  jelly- 
like contents  had  been  turned  out  with  the  fingers;  then  a  dark, 
grumous  fluid  was  evacuated,  changing  in  color  and  density  as  one 
cyst  after  another  was  punctured.  The  pedicle  was  secured  by  a 
silver  suture  passed  like  a  cobbler's  stitch,  and  the  stump  was  re- 
turned into  the  abdominal  cavity.  There  was  nothing  remarkable  to 
note  in  the  convalescence.     She  bore  two  children  afterwards,  and 

'  New  York  Med.  Jouru.,  April,  1876. 


ASCITES.  805 

Dr.  Iladden,  of  tliis  city,  -who  attended  her,  informed  me,  October  6, 
1873,  that  she  had  passed  through  her  hihors  without  difficulty.  Dr. 
Raborg  sums  up  the  points  of  the  case  as  follows:  "The  special  in- 
terest in  the  case  is,  in  the  first  place,  that  a  raultilocular  tumor  should 
rupture,  emptying  the  contents  of  one  of  its  cells  into  the  peritoneal 
cavity,  and  the  patient  survive  the  shock  and  censequent  inflamma- 
tion; secondly,  that  from  the  history  of  the  case  there  is  little  doubt 
that  this  rupture  never  healed,  and  the  secretion  from  the  sac  con- 
tinued to  flow  into  the  peritoneal  cavity  up  to  the  time  of  the  opera- 
tion, or  for  more  tlian  a  year.  The  original  well-marked  tumor  Avithout 
dropsical  eff'usion  around  it,  the  condition  as  witnessed  by  Dr.  Peaslee 
and  myself  after  the  rupture  ;  the  distinctly  marked  tumor  again  after 
nature  had  disposed,  by  diuresis  and  other  means,  of  a  large  portion 
of  the  fluid,  six  weeks  later,  showing  it  was  not  ascitic ;  then  the 
description  given  by  Dr.  Finnell  of  the  appeai-ance  of  the  abdomen 
Avhen  he  tapped  it;  and  finally,  the  fact  that  a  large  quantity  of  fluid 
was  found  by  Dr.  Emmet  Avhen  he  performed  ovariotomy — all  go 
towards  proving  this  assertion  to  be  correct." 

Mr.  Wells,  in  his  Avork  on  "Diseases  of  the  Ovaries,"  reports  a 
case  of  rupture,  where  nineteen  pounds  of  a  calf's-foot-jelly-like 
matter,  which  had  escaped  into  the  peritoneal  cavity,  from  a  rupture 
of  a  multilocular  tumor,  was  removed  together  with  the  tumor.  The 
patient  was  already  several  days  after  the  accident  sufiering  from  a 
low  form  of  peritonitis,  and  died  forty-four  hours  after  the  operation. 
But  he  has  since  saved  the  lives  of  several  other  similar  cases  by 
operating  promptly. 

The  presence  of  ascitic  fluid  and  a  long  existing  peritonitis  are 
closely  connected,  and  furnish  no  special  indication  for  delaying  the 
removal  of  any  coexisting  ovarian  tumor,  although  either  condition 
alone,  or  both  together,  might  influence  the  prognosis.  It  has  been 
thought  that  the  presence  of  fluid  in  the  abdomen  with  a  tumor  was 
a  certain  indication  of  malignant  disease.  This,  however,  has  not 
been  borne  out  by  observation,  although  malignant  growths  in  the 
abdominal  cavity  are  generally  accompanied  by  more  or  less  eff'usion. 

Peritoneal  accumulation  takes  place  occasionally  as  a  simple 
mechanical  effect  of  the  pressure  of  the  tumor.  The  prognosis  is 
affected  by  various  circumstances,  such  as  disease  of  the  heart,  liver, 
or  kidneys,  and  especially  the  latter,  as  the  renal  excretion  is  often 
seriously  diminished  by  the  pressure  of  the  tumor.  Unless  the  growth 
is  of  a  malignant  character,  the  chances  for  recovery  after  its  removal 
are  favorable  ;  the  peritonitis  will  subside,  and  the  accumulation  can 
not  again  take  place.  When  ovarian  tumors  have  become  the  seat  of 
papillary  growths,  peritonitis  and  ascites  are  sometimes  caused  by  rup- 


806  COMPLICATIONS    IN    OVARIOTOMY. 

ture  of  the  cysts  and  the  escape  of  the  fluid  contents  into  the  cavity. 
It  has  been  stated,  when  describing  the  microscopic  apperances  of 
ascetic  fluid,  that  such  a  condition  of  the  ovary  is  not  necessarily 
malignant.  This  opinion  is  based  on  the  fact  that  women  are  known 
to  remain  in  good  health  for  many  years,  and  the  peritonitis  dis- 
appears, notwithstanding  the  peritoneum  may  have  been  for  a  long 
time  bathed  in  fluid  filled  with  the  contents  of  ruptured  cysts.  The 
prognosis,  however,  is  not  so  good  in  these  cises,  as  such  patients  do 
not  bear  tapping  or  the  operation  for  removal  so  well  as  those  with 
simple  ovarian  tumors.  The  accompanying  depression  of  the  vital 
power  is  due  to  the  constant  drain  which  deprives  the  blood  of  its 
most  important  constituents. 

The  presence  of  ascitic  fluid  is  a  great  protection  against  the  for- 
mation of  extensive  adhesions.  Therefore,  when  a  patient  is  tajiped 
for  the  purpose  of  making  a  diagnosis,  as  is  often  necessary,  the 
whole  of  the  fluid  should  never  be  removed  from  the  abdominal  cavity, 
unless  the  operation  is  to  be  performed  immediately. 

The  proper  point  for  tapping  is  in  the  abdominal  Avail  between  the 
umbilicus  and  pubis.  It  has,  however,  been  often  advised  under 
certain  circumstances  to  tap  through  the  posterior  cul-de-sac  of  the 
vagina,  as  it  is  the  most  dependent  point,  but  this  method  is  not  advisa- 
ble. The  following  remarks  made  by  Dr.  Chadwick,  of  Boston,  in  a 
discussion  on  vaginal  ovariotomy,  at  a  meeting  of  the  Gynaecological 
Society,^  fully  coincide  with  my  experience.  "  I  do  not  believe  that 
the  fluid  oi-dinarily  poured  out  by  the  inflamed  peritoneum  should  be 
allowed  to  escape  ;  for  I  regard  it  as  nature's  means  of  floating  up 
the  intestines  from  out  the  pelvis,  and  thus  preventing  adhesions  be- 
tween them  and  the  pelvic  organs,  which  might  subsequently  give  rise 
to  most  unfortunate  complications.  If  that  effusion  were  drained  oif 
by  a  vaginal  opening,  the  uterus,  bladder,  intestines,  etc.,  will  be 
likely  to  contract  adhesions  with  one  another,  from  which  they  may 
not  be  free  for  months,  if  ever.  These  remarks,  however,  do  not  apply 
to  eff'usions  which,  for  one  reason  or  another,  are  undergoing  decom- 
position or  suppuration,  and  are,  therefore,  likely  to  poison  the 
patient's  system,  should  they  be  absorbed." 

Adhesions.— r-Under  ordinary  circumstances,  we  are  able  to  form 
no  idea  as  to  the  existence  or  extent  of  adhesions  previous  to  the 
operation.  When  an  ovarian  tumor  is  felt  from  the  vagina  to  be  un- 
usually low  and  filling  up  the  pelvis,  we  may  suspect  that  adhesions 

1  Gynaecological  Trans.,  vol.  ii,  pp.  27G. 


ADHESIONS.  807 

exist  in  this  neighborliood.  This  supposition  may  be  apparently  con- 
firmed by  the  immovable  condition  of  the  tumor,  and  yet  no  opinion 
based  on  physical  signs  could  be  more  unreliable.  It  is  rare  at  the 
present  day  for  an  operation  to  be  abandoned  on  account  of  the  adhe- 
sions, because  it  is  well  established  that  the  woman's  life  will  be  placed 
in  greater  danger  if  the  operation  be  left  incomplete.  The  extent  of 
the  adhesions  to  the  abdominal  wall  or  omentum  is  deemed  of  little 
consequence.  They  only  become  serious  when  they  exist  between 
the  tumor  and  the  liver,  bladder,  uterus,  or  rectum.  It  has  been 
generally  held  that  extensive  adhesions  to  the  viscera,  which  are  in 
constant  motion,  do  not  take  place.  This  is  true,  as  a  rule,  for  the 
small  intestines  are  rarely  found  involved,  and  the  case  which  I  have 
cited  as  having  the  stomach  and  colon  so  extensively  adherent  to  the 
tumor,  is,  in  all  probability,  unique.  Adhesions  to  the  bladder  are 
to  be  regarded  as  the  most  serious.  This  statement  is  based  on  the 
fact  that  a  degree  of  shock  rarely  met  with  under  other  circumstances, 
particularly  where  the  lesion  is  so  limited  in  extent,  nearly  always 
follows  the  breaking  up  of  such  adhesions.  The  adhesions  to  the 
abdominal  walls  are  always  to  be  torn  from  the  surface  of  the  tumor, 
but  this  method  should  never  be  attempted  when  they  are  situated 
elsewhere.  If  the  tumor  be  found  attached  to  the  liver,  intestines,  or 
bladder,  the  adherent  portion  of  the  sac  must  be  left  undisturbed,  as 
will  be  described  hereafter.  The  walls  of  an  ovarian  cyst  sometimes 
become  a^orlutinated  to  a  greater  or  less  extent  throughout  Doug-las's 
cul-de-sac  along  the  posterior  surface  of  the  uterus,  and  it  would  be 
hazardous  to  separate  them  from  either  the  rectum  or  uterus,  since 
the  hemorrhage  would  be  great,  and  in  a  location  where  it  could  not 
be  controlled.  We  have  no  other  resource  in  such  cases  but  to  re- 
move as  much  of  the  tumor  as  possible,  and  then  attach  the  remainder 
to  the  lower  angle  of  the  wound,  and  this  plan  is  the  only  one  to  be 
adopted  with  certain  forms  of  fibro-cysts.  This  must,  of  course, 
seriously  complicate  the  case,  on  account  of  danger  of  inflammation 
and  blood  poisoning. 

A  drainage  tube  should  be  placed  in  such  a  pouch,  and  when  the 
cyst  is  adherent  to  the  bottom  of  the  cul-de-sac  a  permanent  opening 
into  the  vagina  below  should  be  established,  to  facilitate  the  drainage. 
Under  the  most  favorable  circumstances  the  lining  membrane  of  this 
pouch  will  remain  for  a  time  a  pus-secreting  surface.  If  an  opening 
exists  above,  through  the  abdominal  wall,  and  below  into  the  vagina, 
favorable  results  would  follow  the  injection  of  iodine  and  the  frequent 
washing  out  of  the  cavity.     I  have  lost,  within  a  few  months,  such  a 


COMPLICATIONS    IN    OVARIOTOMY. 

case  from  tetanus,  although  it  had  been  doing  well  for  several  days 
before  the  tetanic  symptoms  developed,  and  I  have  regretted  that  a 
counter-opening  was  not  made  into  the  vagina. 

Dr.  Sims^  advocated,  as  a  guard  against  blood-poisoning,  the  prac- 
tice of  establishing  an  artificial  opening  through  Douglas's  cul-de-sac 
into  the  vagina,  for  the  purpose  of  draining  the  peritoneal  cavity  of 
the  bloody  serous  effusion  always  thrown  out  after  the  breaking  up  of 
adhesions.  The  practice  has,  however,  not  proved  an  advantageous 
one,  from  the  fact  that  the  admission  of  air  and  the  presence  of  the 
foreign  body  needed  to  keep  the  passage  open  excites  a  large  amount 
of  secretion,  which  would  not  otherwise  occur.  But  the  most  import- 
ant objection  is  in  the  exposure  of  the  raw  surfaces  of  the  opening  to 
being  continually  bathed  by  the  fluid  drained  from  above,  thus  sub- 
jecting the  patient  to  a  greater  danger  from  absorption  than  Avould 
exist  under  ordinary  circumstances. 

Where  extensive  adhesions  have  been  separated,  and  the  oozing 
from  the  remaining  raw  surfaces  is  proportionately  great,  it  is  essential 
to  provide  some  outlet  for  it.  M.  Koeberle  first  used  a  glass  tube 
pierced  by  a  number  of  small  holes,  passing  it  to  the  bottom  of  Doug- 
las's cul-de-sac  from  the  lower  angle  of  the  abdominal  section. 
Through  this  tube  the  fluid  drained  away  and  the  cavity  was  washed 
out.  Mr.  Keith  afterwards  brought  it  more  into  practice,  increasing 
the  size  of  the  tube  and  adding  a  rim,  or  flare,  to  prevent  it  from  falling 
into  the  cavity.  Dr.  T.  G.  Thomas  modified  the  shape  of  Keith's 
instrument  by  curving  it  somewhat  in  the  central  portion. 

Dr.  Peaslee-  had  previously  practised  washing  out  the  peritoneal 
cavity  with  an  artificial  serum,  through  an  opening  left  in  the  lower 
angle  of  the  incision,  which  was  kept  closed  by  a  linen  tent.  My 
experience  has  demonstrated  that  this  method  can  only  be  employed 
to  a  limited  extent.  I  have  found  after  death  that  the  exudations 
from  peritonitis  would  become  sacculated  or  break  down  and  be  en- 
cysted as  pus,  within  a  short  distance  of  Douglas's  cul-de-sac,  where 
the  force  of  the  injections  could  not  overcome  the  adhesions,  or,  if 
they  did  overcome  them,  would  produce  fatal  hemorrhage. 

The  Size  and  Long  Existence  of  the  Tumor. — The  size  of  tlie  tumor 
does  not  complicate  the  operation,  unless  this  is  delayed  until  the 
kidneys  or  other  organs  have  received  some  serious  damage  from  long- 
continued  pressure.  The  power  of  enduring  the  discomfort  and  pres- 
sure will,  as  has  been  stated,  vary  with  the  individual. 

'  New  York  Medical  Journal,  1872. 

*  American  Journal  of  the  Medical  Sciences,  Ai>ril,  1863. 


LARGE    TUMOR.  809 

The  history  of  the  following  case  shows  that  this  power  may  exist 
in  a  remarkable  degree,  and,  at  the  same  time,  presents  several  im- 
portant points  of  general  practical  interest. 

Case  LX. — Mrs.  S.,  aged  28,  the  wife  of  a  subordinate  officer 
stationed  at  one  of  the  frontier  posts,  was  admitted  to  the  Woman's 
Hospital  Nov.  25, 1869.  The  tumor  had  developed  in  eleven  months, 
and  in  seeking  relief  she  had  ridden  on  the  back  of  a  mule  for  over  a 
thousand  miles  to  reach  the  nearest  railroad.  During  her  journey 
she  suffered  much  from  pressure  against  the  pommel  of  the  saddle, 
and  the  size  of  the  tumor  had  rapidly  increased.  In  stature  she  was 
below  the  average  height,  and  when  admitted  was  extremely  emaci- 
ated, but  the  girth  of  her  abdomen  Avas  over  fifty-two  inches  at  the 
umbilicus.  The  abdominal  walls,  below  the  level  of  the  umbilicus, 
were  corrugated  and  oedematous;  the  lower  extremities  were  also 
infiltrated,  and  pitted  readily  on  pressure.  She  seemed  to  be  enor- 
mously distended  by  a  multilocular  tumor,  which  encroached  so  much 
upon  the  false  ribs  as  to  push  them  outward.  The  urine  was  ex- 
amined, and  indicated  that  the  kidneys  were  in  a  healthy  condition. 

The  operation  was  performed  December  1st;  present,  Drs.  Isaac 
E.  Taylor,  Post,  Bai'ker,  and  others.  The  abdominal  incision  was 
gradually  extended  to  fourteen  inches  before  the  tumor  could  be 
separated  from  its  adhesions,  which  literally  involved  the  entire  ante- 
rior abdominal  parietes.  The  pedicle,  which  was  broad,  thick,  and 
short,  was  secured  with  silver  wire  by  the  cobbler's  stitch.  The  ope- 
ration was  tedious,  owing  to  the  extensive  adhesions,  and  a  delay  oc- 
curred in  attempting  to  check,  by  the  application  of  the  persulphate 
of  iron  and  pressure,  the  oozing  from  an  extensive  surface  on  the 
abdominal  wall,  high  up  on  the  left  side.  It  was,  at  length,  arrested 
by  having  these  raw  surfaces  held  up  together  in  a  large  fold,  be- 
tween the  hands  of  an  assistant,  while  I  secured  them  in  contact  with 
silver  wire,  introduced  by  four  cobbler's  stitches.  When  this  had 
been  done,  a  fold  or  crest,  about  six  inches  long,  was  left  parallel  to 
the  abdominal  incision.  This  expedient  was  adopted  on  the  spur  of 
the  moment,  from  observing  the  readiness  with  which  the  surfaces 
could  be  thus  secured,  while  they  were  being  held  together  for  the 
purpose  of  making  pressure.  I  employed  the  method  afterwards,  and 
did  not  learn  for  several  years  subsequently  that  Dr.  Kimball,  of 
Lowell,  Mass.,  had  for  some  time  (how  long  I  do  not  know)  secured 
bleeding  surfaces  in  the  same  manner.  Mr.  Wells  also,  as  he  states 
in  his  recently  published  lectures,  had  employed  the  same  method  for 
some  length  of  time  before  he  learned  of  Dr.  Kimball's  practice. 

The  incision  through  the  abdominal  wall  was  closed  with  interrupted 
silver  sutures,  and  with  difficulty.  Notwithstanding  the  serum  had 
been  continually  oozing  from  the  oedematous  tissues,  their  edges  were 
still  thick,  and  it  was  feared  that  the  parts  would  not  be  properly 
adjusted  when  the  oozing  ceased.  To  provide  against  contingency 
the  sutures  were  introduced  at  such  a  distance  from  the  ed'j;es  that  a 


810  COMPLICATIONS    IN    OVARIOTOMY. 

■width  of  at  least  two  inches  of  peritoneal  surfaces  were  brought  to- 
gether. 

The  operation  lasted  two  hours  and  a  quarter.  The  patient  was 
weighed  both  before  and  after  the  operation  as  she  lay  upon  the  table. 
The  tumor  was  thus  found  to  have  weighed  seventy-nine  pounds,  and 
the  patient  only  ninety. 

She  reacted  well,  but  several  abscesses  formed  in  the  line  of  the 
wound,  and  when  the  sutures  were  removed,  there  seemed  to  have 
been  no  union,  in  consequence  of  the  oedematous  state  of  the  tissues, 
and  the  edges  gaped.  For  nearly  the  whole  length  of  the  line  the 
peritoneum  was  put  on  the  stretch,  and  at  one  portion  the  separation 
between  the  edges  Avas  half  an  inch  in  extent.  This  early  union  of 
the  peritoneal  surfaces  was  a  fortunate  circumstance,  as  it  prevented 
the  fluids  from  entering  the  peritoneal  cavity.  The  edges  were  kept 
in  as  close  contact  as  possible,  and  the  traction  upon  the  peritoneum 
relieved  by  the  use  of  adhesive  straps.  The  parts  healed,  to  a  great 
extent,  by  granulations,  and  convalescence  was  necessarily  tedious,  but 
ultimately  there  was  a  good  recovery. 

The  sutures  which  had  been  placed  in  the  fold  of  abdominal  tissue, 
to  arrest  the  oozing,  were  removed  on  the  third  day.  At  that  time  a 
fold  no  longer  existed,  for  in  the  retraction  of  the  over-stretched  tis- 
sues this  had  disappeared,  and  consequently  the  tissues  were  not  put 
on  the  stretch  and  tore  apart  when  the  sutures  were  removed. 

The  recovery  of  this  woman  was  remarkable,  if  we  take  into  con- 
sideration her  size,  the  amount  of  fatigue  she  endured  in  her  condition, 
the  anxiety  of  mind,  the  duration  of  the  operation,  and  the  difficulties 
of  the  convalescence. 

This  was  the  largest  ovarian  tumor  I  have  ever  removed.  The 
average  weight  (Peaslee)  in  Dr.  Keith's  first  hundred  cases  was  thirty 
pounds,  but  he  removed  one  weighing  one  hundred  and  twenty  pounds, 
the  largest  ovarian  tumor  ever  removed  successfully  from  the  living 
body. 

Long  Existence  of  the  Tumor. — But  little  in  addition  can  be  stated 
in  relation  to  the  duration  of  the  tumor,  beyond  what  has  been  already 
advanced.  The  longer  an  ovarian  cyst  has  been  developing,  as  a  rule, 
the  better,  for  the  patient  will  bear  the  operation  with  less  constitu- 
tional disturbance  after  she  has  become  accustomed  to  the  life  of  an 
invalid. 

Pregnancy. — As  a  general  rule  an  ovarian  tumor  should  not  be 
removed  if  darly  pregnancy  coexists,  from  the  fact  tliat  in  a  certain 
proportion  of  cases  miscarriage  will  occur  and  the  patient  die.  But 
it  would  be  equally  wrong  to  permit  a  woman  to  go  to  full  term  with- 
out relief,  if  she  were  likely  in  conse(|uence  of  the  size  of  the  tumor 
to  suffer  from  the  effects  of  the  additional  pressure,  whereby  the  death 
of  both  mother  and  child  may  be  brought  about.     We  have  always  to 


PREGNANCY — CANCER.  811 

recognize  the  danger  of  additional  adhesions  forming  in  some  unusual 
manner  or  place,  as  a  consequence  of  the  displacement  of  the  tumor 
by  the  enlarging  uterus.  These  may  be  of  such  a  character  as  to 
render  the  removal  of  the  tumor  afterwards  impossible,  as  was  the  case 
with  the  patient  in  whom  the  stomach  and  colon  became  adherent  to 
the  tumor.  Mo. .  over,  the  lives  of  both  may  be  lost  if  this  undue 
degree  of  distension  be  permitted  to  continue  Avhen  indications  exist 
of  functional  derangement  in  the  action  of  the  kidneys,  or  of  impaired 
nutrition  elsewhere.  The  danger  of  rupture  of  the  tumor,  and  the 
consequences  to  both  mother  and  child,  must  always  be  considered  in 
advanced  pregnancy,  and  finally  the  evil  effect  of  a  tedious  labor  upon 
the  child,  even  if  the  mother  should  escape,  should  be  remembered. 

If  the  tumor  be  unilocular,  tapping  should  be  resorted  to  for  tempo- 
rary relief.  But  should  it  be  multilocular,  and  the  case,  as  described 
above,  be  an  urgent  one,  the  tumor  should  be  removed  without  delay, 
in  the  interest  of  the  mother.  Fortunately  Avhen  the  operation  is  done 
before  ursemic  symptoms  have  became  marked,  the  recovery  of  the 
mother  will  not  be  complicated  necessarily  by  the  existing  pregnancy, 
and  the  probabilities  will  be  good  for  the  future  progress  of  the  gesta- 
tion to  a  favorable  end. 

Mr.  Wells  has  operated  ten  times,  where  pregnancy  existed,  for 
removing  ovarian  tumors,  having  but  one  death,  all  the  others  recover- 
ing and  going  to  full  term.  He  has  been  successful  also  in  removing 
a  tumor  without  affecting  the  pregnancy,  where  peritonitis  already 
existed  as  a  consequence  of  rupture  of  a  cyst,  and  the  escape  of  its 
jelly-like  contents  into  the  peritoneal  cavity. 

Dr.  Sims  removed,  in  1860,  a  very  large  unilocular  cyst,  without 
adhesions,  from  a  private  patient,  between  the  third  and  fourth  months 
of  pregnancy.  I  had  charge  of  her  after  the  operation ;  the  pulse 
never  rose  above  ninety  per  minute ;  she  recovered  without  a  bad 
symptom,  and  had  three  children  afterwards. 

Dr.  W.  L.  Atlee  also  operated  on  a  case  under  the  same  circum- 
stances, and  without  any  bad  consequences. 

Dr.  Playfair  has  collated  (Peaslee)  fifty-seven  cases  of  this  com- 
plication, in  thirteen  of  Avhich  the  mothers  Avere  lost ;  in  seven  cases 
where  the  cyst  was  punctured,  they  all  did  Avell,  and  gestation  was 
not  interrupted.  Dr.  Braxton  Hicks  cites  eight  instance  of  ovarian 
tumors  complicated  with  pregnancy  which  went  to  full  term,  and  were 
delivered  of  living  children. 

Cancer,  Phthisis,  Diseases  of  the  Kidneys,  etc. — We  may  be  able 
to  recognize  the  existence  of  cancer  by  microscopic  examination,  but 


812  COMPLICATIONS    IN    OVARIOTOMY. 

we  can  form  no  estimate  as  to  the  extent  of  adhesions,  in  a  knowledge 
of  which  must  rest  the  advisability  of  attempting  to  remove  the  mass. 
Therefore,  in  every  instance,  after  withdrawing  the  ascitic  fluid,  the 
abdominal  incision  must  be  enlarged  sufficiently  for  the  purpose  of 
gaining  this  information.  The  patient  must  always  have  the  benefit 
of  the  doubt,  since  she  can  have  but  a  very  limited  future  if  a  growth 
of  this  character  be  left  undisturbed,  while  it  is  a  well-admitted  fact 
that  she  may  gain  a  new  lease  of  life,  for  an  indefinite  time,  if  certain 
growths  are  thoroughly  removed,  Avhich  might  in  time  become  malig- 
nant in  character.  Should  the  appearance  of  the  patient  indicate  the 
cachexia,  so  characteristic  of  the  advanced  stages  of  malignant  disease 
in  other  parts  of  the  body,  the  operation  for  removal  should  not  be 
attempted.  We  may  prolong  life  by  tapping,  but  more  than  this 
should  not  be  attempted,  for  the  nerve  centres  are  already  poisoned 
by  the  condition  of  the  blood,  and  the  patient  is  consequently  unable 
to  react  from  the  slightest  shock. 

Phthisis  is  fortunately  not  a  common  complication,  although  it  may 
exist  in  a  certain  proportion  of  cases,  and  its  origin  may  be  in  some  way 
related  with  the  development  of  the  tumor ;  but  the  coexistence  of  the 
two  is  usually  a  coincidence.  In  the  early  stages  of  the  pulmonary 
trouble,  the  deposit  of  tubercle  may  be  at  least  temporarily  arrested 
by  removing  the  ovarian  tumor,  so  that  the  pulmonary  circulation  may 
be  less  obstructed.  In  the  advanced  stages  of  the  disease,  no  other 
benefit  can  be  hoped  for  from  any  operative  procedure  beyond  relief 
to  the  breathing,  and  when  this  can  be  obtained  by  tapping,  it  should 
be  employed. 

The  Condition  of  the  Kidneys  is  a  most  important  matter  in 
ovariotomy,  for  on  their  even  more  than  usual  activity  depends  a 
favorable  termination  in  every  case,  unless  it  be  unusually  simple  in 
character.  Any  functional  disturbance  of  them  will  be  relieved  by 
increased  action  of  the  skin,  and  will  entirely  disappear  after  the  re- 
moval of  the  tumor.  But  if  advanced  organic  disease  exists,  we  must  be 
prepared,  in  all  probability,  for  a  fatal  termination  of  the  ovariotomy. 
I  am  confident  that  I  have  lost  a  case  after  removing  the  tumor,  in 
consequence  of  disease  of  the  kidneys,  their  action  having  been  entirely 
arrested  in  the  effort  to  eliminate  the  ether.  We  should  always  be 
on  the  lookout  to  prevent  the  kidneys  from  being  over-worked,  and 
endeavor  to  relieve  them  by  inducing  an  increased  action  of  the  skin 
and  bowels. 

When  other  organic  diseases  complicate  ovarian  tumors,  we  must 


UTERINE    TUMORS — DISEASE    OF    THE    OTHER    OVARY.      813 

determine  in  each  individual  case  the  propriety  of  operating,  or  of 
gaining  temporary  relief  and  time  by  tapping. 

Uterine  Fibrous  Tumor. — This  complication  is  not  common,  I 
have  met  with  but  a  single  instance,  the  one  referred  to  by  Dr.  Peaslee 
in  his  Avork  (page  97).  In  this  case  ascites  also  existed,  and  it  was 
necessary  to  tap  before  the  diagnosis  could  be  fully  formed.  Dr. 
Peaslee  states  that  he  had  met  with  several  instances.  As  long  as 
the  two  tumors  (ovarian  and  uterine)  are  but  moderately  enlarged,  it  is 
not  difficult  by  means  of  a  sound  in  the  uterus  to  judge  of  their  mutual 
relation.  If  in  operating,  the  abdominal  section  be  made  sufficiently 
large,  the  presence  of  the  uterine  growth  will  scarcely  add  much  to 
the  difficulties  of  removing  the  ovarian  tumor.  If  the  complicating 
uterine  tumor  were  a  fibro-cyst  instead  of  a  fibrous  growth,  it  would 
be  somewhat  likely  to  become  pedunculated  by  the  pressure  of  the 
ovarian  tumor,  sufficiently  to  admit  of  its  removal  also. 

Disease  of  the  Remaining  Ovary. — It  is  not  uncommon  to  find  a 
tumor  in  each  ovary  in  difierent  degree  of  development.  Koeberle 
found  both  ovaries  involved  in  nearly  one-fifth  of  all  of  his  cases,  a 
somewhat  larger  proportion  than  is  found  by  other  operators.  But  all 
have  met  with  a  certain  number,  and  it  seems  to  be  the  general  ex- 
perience that  double  ovariotomy  does  not  materially  increase  the  risk 
of  the  operation. 


811  GENERAL    DETAILS    IN    OVARIOTOMY. 


CHAPTER    XLII. 

GENERAL  DETAILS  IN  OVARIOTOMY. 

Proper  time  for  operating — Preparatory  treatment — Instrnments — Preparations 
for  the  operation — Mode  of  treating  the  pedicle. 

Proper  Time  for  the  Operation. — No  inflexible  rule  can  be  laid 
down  as  to  the  proper  time  for  removing  an  ovarian  tumor.  Each 
case  is  a  law  unto  itself  in  this  respect,  to  determine  which  a  ripe 
experience  and  a  careful  judgment  are  essential.  Some  women  suifer 
more  at  an  early  stage  than  others  do  later,  even  when  there  is  a 
considerable  degree  of  distension.  Some  bear  the  suspense  badly, 
and  their  anxiety  of  mind  tends  so  greatly  to  impair  their  physical 
condition  that  an  early  operation  is  imperative.  In  general  terms 
surgical  interference  should  be  delayed  until,  as  has  been  stated,  it 
becomes  evident  that  the  general  system  is  beginning  to  be  aff'ected, 
as  indicated  by  loss  of  flesh  about  the  neck  and  upper  part  of  the 
chest,  by  disturbance  of  digestion,  and  by  more  or  less  obstruction  to 
the  action  of  the  lungs  and  heart.  A  judicious  delay  enables  the 
peritoneum  to  become  more  tolerant  to  irritation  and  much  less  liable 
to  inflammation  than  it  would  be  were  the  tumor  removed  at  an  early 
stage  of  its  growth.  On  the  other  hand,  the  patient  may  be  deprived 
of  all  chances  of  recovery  should  the  removal  be  delayed  until  the 
vital  poAvers  become  so  much  depressed  that  she  cannot  react  from 
the  shock  of  the  operation.  The  best  results  then  may  be  expected 
as  soon  as  the  patient  has  been  toned  down,  or  physiologically 
adapted,  as  it  were,  to  the  operation,  and  success  will  be  the  more 
certain  if  she  is  buoyed  up  by  a  firm  assurance  of  recovery. 

Preparatory  Treatment. — It  is  very  important  to  bring  about  a 
healthy  action  of  the  bowels,  skin,  and  kidneys  previous  to  operating. 
The  long-continued  pressure  of  tbe  tumor  induces  a  greater  or  less 
accumulation' of  feces,  which  should  be  removed  as  well  for  the  com- 
fort of  the  patient  as  for  the  success  of  the  operation.  The  means  to 
be  employed  for  the  removal  of  the  scybalee  Avill  also  remove  the 
flatus.  Without  this  preparatory  treatment  the  operation  is  often 
rendered  more  difficult  of  execution,  and  the  ultimate  success  more 


PREPARATORY    TREATMENT.  815 

uncertain,  "Whenever  the  intestines  are  distended  by  flatus,  it  is 
almost  impossible  to  keep  them  within  the  abdominal  cavity  during 
the  operation;  moreover,  any  increase  in  their  bulk,  by  distension, 
may  render  it  difficult  to  make  any  inspection  that  may  be  necessary 
for  detecting  the  source  of  bleeding.  The  comfort  of  the  patient 
also,  after  the  operation,  may  be  diminished  by  flatus  in  the  bowels, 
and  if  the  pedicle  is  short,  and  has  been  secured  in  the  wound  by 
clamp  or  stitch,  it  may  be  so  much  displaced  as  to  bleed,  or  so  much 
irritation  may  be  established  as  to  excite  peritonitis. 

A  proper  condition  of  the  skin  tends  to  insure  a  healthy  action  of 
the  bowels,  kidneys,  liver,  and  lungs,  which  will  render  the  circulation 
in  the  capillaries  more  active  and  thus  diminish  the  risk  of  inflamma- 
tion and  blood-poisoning.  My  experience  leads  me  to  believe  that  a 
certain  proportion  of  cases  suff'er  from  peritonitis,  and  possibly  septi- 
caemia, after  the  operation,  because  the  action  of  the  skin  has  not 
been  previously  attended  to. 

The  influence  exerted  on  the  other  organs  by  a  healthy  action  of 
the  skin  is  a  fact  too  well  established  to  need  any  further  discussion. 
It  is,  therefore,  evident  that,  if  the  skin  be  inactive,  the  elimination 
of  any  new  poisonous  material  resulting  from  the  operation  will  be 
greatly  lessened.  During  the  progress  of  ovarian  tumor  the  circula- 
tion tends  to  become  so  imperfect  in  the  capillaries  that,  even  under 
the  most  favorable  circumstances,  the  skin  is,  as  a  rule,  dry  aad  in- 
active. Hence  I  always  address  my  treatment  flrst  to  the  skin,  and 
find  that  the  bowels  are  thereby  more  easily  acted  on  afterwards. 

A  steam  bath  is  the  most  beneficial  in  its  effect,  and  where  this 
cannot  be  obtained  a  hot-water  bath  may  be  given.  After  the  body 
has  been  well  washed  with  soap,  and  dried,  the  skin,  particularly  of 
the  extremities,  must  be  rubbed  thoroughly  by  the  hand  smeared 
with  vaseline.  The  body  should  be  wiped  off"  with  a  piece  of  soft 
flannel,  so  as  to  remove  all  excess  of  gi-ease,  some  hot  diluent  drink 
administered,  the  patient  then  covered  up  warm  in  bed  to  increase 
the  action  of  the  skin,  and  to  obtain  rest  by  sleep.  This  process 
might  be  gone  through  with  for  several  nights  just  previous  to  the 
operation,  or  employed  two  or  three  times  a  week  if  there  should  be 
no  urgency  in  the  case. 

Whenever  the  condition  of  the  patient  will  admit  of  it  a  brisk  cathar- 
tic should  be  administered,  with  the  view  of  unloading  the  portal  system. 
Podophyllin  often  answers  well  for  this  purpose,  and  its  irritating 
effects  may  be  generally  counteracted  by  combining  with  it  a  small 
quantity  of  the  extract  of  belladonna.     But  I  employ  a  combination 


816  GENERAL    DETAILS    IN    OVARIOTOMY. 

of  calomel  and  soda  more  frequently  than  any  other  purgative,  follow- 
ing it  by  several  doses  of  castor  oil,  which  is  the  most  reliable  of 
cathartics  when  the  strength  of  the  patient  is  much  reduced. 

Without  regard  to  the  special  cathartic  employed,  it  Avill  always  be 
beneficial  to  administer  one  or  more  enemata  of  hot  water  and  inspis- 
sated ox-gall,  the  patient  being  placed  on  the  knees  and  elbows,  after 
the  manner  already  described.  Thus  given  these  enemata  distend  the 
colon  and  constitute  the  most  efficient  means  at  our  command  for 
removing  both  scybalge  and  flatus. 

As  recommended  by  the  late  Dr.  Peaslee,  the  patient's  diet  should 
consist  chiefly  of  milk  porridge  for  several  days  before  the  operation. 
This  is  made  by  boiling  for  an  hour,  equal  parts  of  milk  and  water, 
thickened  with  flour,  with  the  addition  of  salt  in  preference  to  sugar. 
It  has  been  found  that  this  diet  does  not  distend  the  intestines  with 
flatus,  and  that  under  it  the  patient  suffers  less  from  fecal  accumula- 
tion. AYhen  meat  is  needed,  thick  and  tender  lamb  rib  chops,  just 
cooked  through,  and  not  under-done,  answer  Avell,  as  they  are  more 
easily  digested  than  any  other  meat  except  that  from  the  breast  of 
game  birds.  It  is  advisable  that  the  diet  of  the  patient,  for  several 
days  before  the  operation,  should  be  of  the  simplest  character  con- 
sistent with  the  maintenance  of  her  strength.  To  insure  the  best 
physical  condition  for  the  operation  it  will  be  necessary  for  the  patient 
to  obtain  undisturbed  rest  during  the  previous  night,  and  to  guard 
against  the  ill  eff"ects  of  over-anxiety  an  anodyne  should  always  be 
administered.  About  noon,  or  shortly  afterwards,  the  patient  will  be 
found  in  the  best  condition  for  the  operation.  Some  three  hours 
should  have  elapsed  after  taking  food  before  administering  the  anaes- 
thetic, and  if  in  the  mean  time  it  be  necessary  to  sustain  the  patient, 
a  little  beef-tea  and  brandy  should  be  injected  into  the  rectum. 

At  the  time  of  the  operation  the  patient  should  be  clothed  in  a  flan- 
nel shirt  and  drawers,  a  night  gown  and  stockings.  As  the  last  thing 
before  entering  the  operating  room  the  patient  should  empty  her 
bladder. 

It  is  all-important  in  this,  as  in  any  other  capital  surgical  operation, 
that  the  day  selected  should  be  bright  and  clear,  with  a  westerly 
wind,  for  our  portion  of  the  world.  A  cold,  raw,  and  easterly  wind 
will  sensibly  affect  the  nervous  system  of  any  healthy  organization, 
and  may  cause  the  death  of  a  patient  when  in  a  feeble  condition.  The 
depressing  effects  of  an  easterly  wind,  ladened  with  moisture,  will  be 
well  marked  on  the  nerve  centres  of  a  feeble  organization,  rendering 
reaction  from  the   shock  of  the  operation  difficult.      Whenever  the 


INSTRUMENTS.  817 

patient  is  feeble,  I  never  hesitate  to  postpone  tlie  operation  to  a 
more  favorable  day,  unless  reasons  exist  which  render  delay  inad- 
A'isable. 

A  room  Avith  the  windows  having  a  southerly  or  westerly  exposure 
is  best  fitted  for  the  operation ;  its  temperature  must  be  kept  at  80° 
throughout  the  whole  time. 

A  table  similar  to  the  one  for  ordinary  examinations  will  answer 
for  the  operation.  It  should  be  covered  in  the  same  manner  by  several 
blankets,  and  over  all  a  sheet  of  India-rubber  cloth.  Several  pillows 
are  needed.  The  operating  table  must  be  placed  near  the  window, 
so  that  the  lower  limbs  of  the  patient  will  be  in  that  direction,  leaving 
space  enough  for  a  small  table,  to  be  used  for  the  instruments,  and 
for  the  assistant  to  stand  in  charge  of  the  spray  apparatus. 

The  number  of  instruments  recommended  for  this  operation  is 
most  formidable,  but  the  essentials,  in  addition  to  the  ordinary  gynai- 
cological  case,  are  very  few.  A  scalpel,  a  few  pairs  of  forceps  for 
seizing  bleeding  vessels,  a  grooved  director,  a  trocar  having  several 
feet  of  tubing  attached,  vulsella  for  drawing  out  the  sac,  a  clamp  for 
securing  the  pedicle,  a  cautery  apparatus,  sponge  holders,  various 
scissors,  a  glass  drainage  tube,  needles,  and  the  usual  instruments  for 
applying  silver  sutures.  All  these  should  be  thoroughly  cleansed 
and  placed  on  the  table  in  a  shallow  vessel  containing  some  disin- 
fecting fluid.  A  number  of  large,  straight  sewing  needles,  like  those 
used  for  the  perineum,  should  be  threaded  with  a  short  loop  to  which 
the  silver  wire  must  be  already  attached.  Several  silk  ligatures 
of  sufficient  strength,  but  not  too  large,  should  be  prepared  for  the 
pedicle,  if  to  be  secured  by  this  method,  together  with  a  number 
of  ligatures  for  securing  bleeding  vessels.  All  of  these  should  be 
placed  together  at  some  convenient  point,  and  under  the  special  charge 
of  an  assistant.  A  number  of  pieces  of  linen  w^ith  the  edges  hemmed, 
and  about  eight  inches  square,  should  be  provided  and  placed  in  a 
solution  of  carbolic  acid.  These  are  to  cover  the  tissues  as  they  are 
handled  ;  they  were  first  used  by  Koeberle. 

It  is  of  sufficient  importance  for  the  operator  himself  to  examine 
carefully  the  sponges.  They  should  be  fresh  sponges  carefully 
selected  and  prepared  for  the  operation.  All  portions  of  shell  or  other 
foreign  matter  must  be -first  carefully  picked  out,  and  the  sponges 
well  washed  with  soap  and  thoroughly  boiled  for  some  time.  It  is 
well  to  expose  them  for  several  days  to  the  action  of  the  sun,  pick 
them  over  again  and  finally  wash  them  in  a  hot  solution  of  carbolic 
acid  ;  they  may  then  remain  until  used  in  a  weak  solution  of  the  acid. 
52 


818 


GENERAL    DETAILS    IN    OVARIOTOMY. 


A  spray  apparatus,  or  better  two,  should  be  selected  Avith  a  suffi- 
cient capacity  to  remain  in  operation  for  at  least  two  hours  without 
needing  to  be  replenished.  A  number  of  these  have  been  devised  in 
this  country,  more  or  less  on  the  plan  of  Lister's  original  instrument. 
The  modifications  by  Drs.  Weir,  Thomas,  and  Hanks  are  in  more 
general  use,  and  each  has  some  special  point  to  recommend  it. 

Fig.  123. 


Weir's  steam  sj  ray  apparatus. 

^Three  solutions  of  the  carbolic  acid  will  be  needed,  and  that  for 
the  spray  apparatus  should  be  made  from  absolutely  pure  phenol,  as  it 
is  found  to  be  more  soluble  and  less  irritating.  The  first  solution 
should  be  in  the  propoi'tion  of  1  to  40,  to  be  used  for  the  protective 
and  the  gauze  covering.  The  second  solution  for  the  spray  should  be 
1  part  to  30,  and  the  third  solution  1  to  20.  The  latter  solution  will 
be  of  the  strength  needed  for  purifying  the  sponges  and  all  the  in- 
struments, and  they  should  be  allowed  to  remain  in  it  for  at  least  half 
an  hour  before  commencing  the  operation.  It  is  yet  a  question  to 
be  determined  by  experience,  if  other  agents,  less  irritating  and  at 
the  same  time  as  effective,  can  be  used  in  the  place  of  the  carbolic 
acid  spray.  Salicylic  acid  has  been  used  in  the  proportion  of  1  to 
800,  but  it  has  no  advantage  over  the  thymol  solution  which  is  un- 
irritating  ;  but  this  has  yet  to  be  subjected  to  further  test,  and  its 


•  To  Dr.  Robert  F.  Weir,  I  am  indebted  for  all  my  knowledge  on  this  subject, 
obtained  either  by  personal  instruction  from  himself,  or  from  his  paper  "On 
the  Antiseptic  Treatment  of  Wounds  and  its  Results,"  New  York  Medical  Journal, 
Dec.  1877,  and  Jan.  1878,  to  which  I  refer  the  reader  for  more  general  informa- 
tion on  the  subject. 


DRESSINGS — ASSISTANTS.  819 

greater  efficacy  proved  before  the  carbolic  acid  is  to  be  abandoned 
for  it. 

The  formula  used  at  the  Woman's  Hospital  for  preparing  the 
thymol  solution  is  fifteen  grains  of  thymol  to  three  drachms  of  alcohol, 
half  an  ounce  of  glycerine,  and  thirty-four  ounces  of  water.  The 
directions  are  to  heat  the  alcohol  until  it  is  hot,  dissolve  the  thymol 
in  it,  and  then  add  the  glycerine  and  water. 

The  tissues  constituting  Lister's  dressings  are,  antiseptic  gauze,  a 
coarse  cotton  fabric,  known  in  commerce  as  cheese  cloth,  carbolized 
by  a  certain  process  ;  some  mackintosh  or  thin  rubber  cloth  to  cover 
the  abdomen,  some  oil  silk,  which  has  received  a  thin  layer  of  varnish 
on  one  side  through  which  the  carbolic  acid  cannot  penetrate,  and  called 
the  protective  ;  and  a  quantity  of  carbolized  jute.  The  ligatures, 
whether  of  silk  or  catgut,  should  also  all  be  carbolized. 

Six  assistants  will  be  needed,  and  the  spectators  should  be  limited 
in  number. 

A  warm  blanket  should  be  spread  over  the  lower  end  of  the  table, 
with  which  to  envelop  the  legs  and  feet  of  the  patient  as  they  hang 
over  to  rest  upon  a  chair.  Her  nightgown  and  undershirt  should  be 
rolled  up  to  a  point  at  which  they  cannot  become  soiled.  A  small 
pillow  should  be  pushed  under  the  middle  of  her  back  for  support,  and 
the  other  pillows  so  placed  at  an  angle  as  to  make  her  position  com- 
fortable. The  operator  will  select  the  side  of  the  patient  on  which 
he  is  to  stand,  according  to  the  direction  of  the  light,  or  as  he  may 
have  a  preference.  He  will  then  need  an  assistant  to  stand  between 
him  and  the  instrument  table,  but  just  behind  him,  so  as  not  to  obstruct 
the  light  or  spray.  His  chief  assistant  will  stand  on  the  other  side 
of  the  operating  table  opposite  to  him,  ready  to  sponge  when  necessary. 
A  third  person  may  stand  at  the  side  of  the  chief  assistant  nearest  the 
patient's  head  for  the  purpose  of  keeping  up  steady  pressure,  while 
the  tumor  is  being  emptied.  This  he  does  by  applying  his  open  hands 
flat  on  each  side  of  the  abdomen.  Afterwards  he  may  be  "needed  to 
assist  the  person  giving  ether,  and  to  look  after  the  condition  of  the 
patient,  and  to  give  hypodermic  injections  of  brandy,  if  they  shall  be 
needed.  The  person  administering  the  anaesthetic  should  be  particu- 
larly skilled  therein,  and  so  familiar  with  the  operation  that  he  may 
not  neglect  the  anaesthesia  in  his  anxiety  to  witness  it.  The  operator 
should  on  no  account  have  his  attention  called  from  the  work  before 
him.  The  fifth  assistant  should  have  charge  of  the  spray  apparatus, 
and  the  sixth  one  is  to  wash  the  sponges.  The  assistant  with  the 
spray  should  stand  by  the  window  on  the  side  of  the  instrument  table 


820  GENERAL    DETAILS    IX    OVARIOTOMY. 

opposite  to  the  operator,  with  a  rest  for  the  apparatus,  so  that  the 
spray  may  be  directed  obliquely  along  the  line  of  the  incision  and  just 
over  it,  avoiding  the  patient's  face. 

As  the  patient  passes  under  the  influence  of  the  ether,  a  folded 
napkin  should  be  placed  between  her  knees,  the  legs  tied  together 
and  secured,  if  necessary,  to  the  back  of  the  chair,  or  better  to  the 
table.  A  piece  of  oiled  silk  four  feet  long  and  not  quite  so  wide 
should  be  placed  over  the  bare  abdomen.  From  the  centre  of  this  a 
circular  piece,  sufficiently  large,  is  to  be  removed,  and  the  edges  of 
the  oiled  silk,  to  the  width  of  an  inch  or  more,  spread  with  the  material 
for  forming  an  adhesive  plaster.  This  opening  will  expose  a  suffi- 
cient portion  of  the  abdominal  wall  to  allow  the  operation  to  be  com- 
pleted. As  the  edges  of  the  oiled  silk  are  adherent  all  around,  the 
clothing  below  will  be  protected,  as  well  as  a  portion  of  the  patient's 
body.  A  large  receptacle  must  be  placed  under  the  table  for  receiv- 
ino-  the  contents  of  the  tumor,  and  alongside  of  it  a  small  hand-bowl, 
to  be  used  for  the  same  purpose  when  more  convenient.  Xear  by 
must  be  placed  a  supply  of  towels  and  a  basin  of  warm  water,  in 
which  the  operator  may  dip  his  hands  from  time  to  time,  and  it  should 
be  the  duty  of  some  one  person  to  change  frequently  the  water  during 
the  operation.  Before  beginning  the  operation  it  must  be  seen  that 
in  front  of  the  fire,  or  heating  apparatus,  have  been  placed  several 
blankets,  a  change  of  clothing  for  the  patient  in  case  she  should  need 
it,  and  a  sufficient  supply  of  hot  water.  The  patient's  bed  must  also 
bs  properly  prepared.  It  should  be  narrow,  that  the  patient  may  be 
readily  reached ;  the  mattress  should  be  of  hair,  and  hard,  protected 
by  a  rubber  sheet,  and  covered  by  a  blanket  and  cotton  sheet  for  the 
patient  to  lie  upon.  Along  the  centre  of  the  bed  a  number  of  vessels 
of  hot  water,  tightly  corked,  are  to  be  placed,  and  covered  up  by  the 
bed  clothing. 

Every  preliminary  detail  having  been  attended  to,  it  remains  for 
the  surgeon  to  prepare  himself  for  the  operation.  The  most  im- 
portant  part  of  this  will  consist  in  thoroughly  cleansing  his  hands, 
for  the  death  warrant  of  many  a  patient  is  carried  under  the  nails 
of  the  operator.  The  nail-brush  must  be  used  with  hot  water  and 
soap,  and  carbolic  acid  afterwards.  Moreover,  the  chief  assistant, 
the  one  who  is  charged  with  washing  the  sponges,  and  any  one  who 
is  likely  to  be  called  upon  to  handle  the  sponges  or  instruments,  or 
to  place  his  hand  in  the  wound,  should  cleanse  and  disinfect  his 
hands  in  the  same  manner. 

Mode  of  Securing  the  Pedicle. — In  order  to  avoid  repetition,  and  not 
to  be  interrupted  in  our  description  of  the  operation  proper,  we  will 


SECURING    THE    PEDICLE.  821 

first  consider  tlic  different  modes  of  treating  or  securing  the  pedicle. 
The  best  method  is  still  an  open  (piestion,  but,  if  the  operator  has  no 
preference,  it  is  determined  somewhat  by  the  character  of  the  pedicle, 
the  choice  lying  between  the  use  of  the  clamp  or  ligature,  and  possibly, 
the  cautery,  under  certain  circumstances.  Sometimes  the  tumor  is 
enucleated  in  the  absence  of  a  pedicle.  In  general  terms  it  may  be 
stated  that  the  use  of  the  clamp  is  to  be  restricted  to  a  long  pedicle, 
and  the  cautery  to  a  narrow  one  with  small  vessels.  The  ligature, 
in  all  probability,  will  become  in  the  future  the  means  generally 
employed  for  securing  the  pedicle.  For  a  number  of  years  I  have 
used  the  silk  ligature  exclusively  for  this  purpose,  and  have  dropped 
the  pedicle  back  into  the  abdominal  cavity,  although  I  had  been  pre- 
viously opposed  to  the  practice.  The  opposition  to  the  ligature  was 
based  entirely  on  theoretical  views  :  I  feared  that  the  silk  would  act  as 
a  foreign  body  and  lead  to  the  formation  of  abscesses,  but  experience 
has  disproved  this. 

In  ray  first  operations  I  ligated  and  attached  the  pedicle  in  the 
lower  angle  of  the  wound,  as  had  been  recommended  by  Langenbeck, 
and  afterwards  by  Dr.  H.  R.  Storer.  Then  I  employed  for  a  short 
time  the  clamp,  which  proved  in  my  hands  the  least  satisfactory 
method  for  treating  the  pedicle.  For  several  years  afterwards  I 
secured  the  pedicle  by  means  of  silver  wire  introduced  like  a  shoe- 
maker's stitch. 

Dr.  Peaslee  in  his  work,  page  442,  credits  Dr.  Murray,  of  the 
Great  Northern  Hospital,  London,  with  having  proposed,  in  1865, 
the  application  of  a  ligature  to  the  pedicle  in  the  form  of  the  figure 
8,  and  states  that  "Dr.  T.  A.  Emmet  reported  his  use  of  the  silver 
wire  in  the  same  way  in  1870"  QAm.  Journ.  of  Obstetrics).  This 
is  an  error,  as  I  seldom  used  the  figure-of-8,  but  took  at  least  three 
stitches,  and  the  number  could  be  extended  indefinitely,  like  cobbler's 
stitches,  while  Dr.  Murray's  purpose  was  simply  to  secure  the  pedicle, 
by  silk  or  any  other  means,  in  two  sections. 

I  used  a  somewhat  larger  wire  than  that  generally  employed  for 
surgical  purposes,  and  in  sections  about  a  foot  long,  with  a  large 
straight  needle  attached  at  each  end,  the  wire  being  twisted  through 
the  eye. 

While  an  assistant  held  up  the  pedicle,  so  that  the  light  might  be 
transmitted,  I  selected  a  spot  clear  of  vessels,  through  which  I  passed 
a  needle,  and  from  the  other  side  another  needle,  along  the  same 
tract,  but  in  opposite  directions.  This  was  repeated  at  short  distances 
and  the  intervals  between  the  stitches  were  compressed  by  tightening 


822  GENERAL    DETAILS    IN    OVARIOTOMY. 

the  wires.  The  pedicle  would  be  thus  included  iu  three  or  four  sec- 
tions, according  to  its  size,  and  the  ends  of  the  wires  were  twisted  and 
cut  off.  At  each  section,  in  turn,  the  wire  was  tightened,  but  before 
being  twisted,  the  stump  of  the  pedicle  was  seized  bj  the  operator, 
between  the  thumb  and  fore-finger,  and  traction  was  made  first 
on  one  wire  and  then  on  the  other.  If  traction  were  made  on  both 
ends  at  the  same  time,  only  one  section  would  be  compressed,  for  the 
suture  would  bind  where  the  wires  crossed.  But  Avith  traction  on  one 
at  a  time  the  wire  would  be  drawn  straight  so  that  the  tissues  could 
then  be  easily  run  together,  as  it  were,  or  compressed  between  the 
fingers,  and  then  the  other  wire  could  be  drawn  up  in  the  same  manner. 
The  ends  were  twisted,  bent  flat  and  cut  off,  with  the  twisted  portion 
about  an  eighth  of  an  inch  in  length.  The  wire  when  thus  used  re- 
mained so  imbedded  in  the  tissues  and  covered  by  the  stump  as  to 
be  hidden,  where  it  became  encysted  and  caused  no  irritation  after- 
wards. 

I  used  a  temporary  clamp,  placed  generally  next  to  the  uterus, 
and,  that  the  tissues  should  not  be  bruised,  I  employed  one  made  on 
the  principle  of  that  used  with  Chapman's  India-inibber  ice  bags,  in 
which  simple,  round,  and  flat  surfaces  are  brought  together.  Then 
just  before  the  ends  of  the  wires  were  twisted,  but  while  in  the  grasp 
of  the  forceps,  the  clamp  was  always  carefully  loosened.  If  bleeding 
then  took  place,  the  wires  were  drawn  tighter,  while  the  escape  of 
blood  could  be  easily  controlled  by  the  grasp  of  the  fingers. 

If  oozing  should  occur  from  one  particular  section,  after  the  ends 
of  the  wires  have  been  secured,  it  is  easy  to  tighten  that  portion  by 
hooking  a  tenaculum  under  the  wire,  and  giving  it  several  turns  upon 
itself.  This  suture  should  be  placed  as  near  to  the  uterus  as  can  be 
done  without  causing  undue  traction,  and  with  the  purpose  of  leaving 
the  stump  clear  for  an  inch  or  more  beyond  the  constricted  portion. 
If  this  precaution  be  neglected  and  the  tissues  are  trimmed  too  close 
to  the  suture,  the  portion  of  pedicle  within  the  grasp  of  the  end  loop 
maybe  pulled  out  by  the  traction,  and  the  patient  die  from  loss  of 
blood. 

I  am  ignorant  of  any  other  means  for  securing  the  pedicle,  except 
the  clamp,  which  can  compress  the  tissues  within  so  small  a  bulk  as 
can  be  done  with  the  cobbler's  stitch.  I  secured  the  pedicle  in  some 
fifteen  cases  by  this  means,  and  with  a  single  exception,  Avhere  I  cut 
the  tissues  too  close,  I  was  fully  satisfied  with  its  use.  In  this  case 
it  was  found,  after  death,  that  nearly  a  pint  of  blood  had  been  gradu- 
ally lost,  during  some  three  days,  from  a  portion  of  the  pedicle  which 


SECURING    THE    PEDICLE.  823 

had  slipped  from  the  end  loop.  If  the  hemorrhage  had  not  heen  the 
immediate  cause  of  death,  which  was  probably  the  case,  the  conse- 
quence would  have  been  serious,  if  the  patient  had  ever  reacted.  I 
had  been  closely  Avatching  Dr.  Peaslee's  practice  for  some  time,  and 
finding  that  his  results  were  good  from  the  use  of  the  silk  ligature,  I 
abandoned  the  silver  Avire.  Yet  there  are  conditions  where  the  cob- 
bler's stitch  might  be  employed  with  great  advantage  for  bringing  sur- 
faces together  about  the  pelvis,  and  Avhen  an  interrupted  suture  can- 
not be  applied  with  accuracy.  It  can  be  used  in  vascular  tissue  with 
more  safety  than  any  other  suture,  and  even  if  the  stitch  should  pass 
through  the  centre  of  a  large  vessel,  the  bleeding  would  be  arrested 
by  the  compression  exerted  on  all  sides.  The  silver  wire  becomes 
so  thoroughly  encysted  that,  when  death  occurs  after  a  week,  it  is 
exceedingly  difficult  to  find  it. 

In  some  respects  iron  Avire,  even  of  a  smaller  diameter,  might  be 
preferable  on  account  of  its  strength,  and  from  the  fact  that  the  iron 
may,  in  time,  become  oxidized  and  be  absorbed. 

Dr.  Nathan  Smith,  of  Connecticut,  in  1821,  according  to  Dr.  Peas- 
lee,  was  the  first  to  ligate  the  vessels  of  the  pedicle,  to  then  cut  the 
ends  of  the  ligatures  short,  return  the  stump,  and  close  the  external 
wound.  Dr.  D.  L.  Rogers,  of  Ncav  York,  in  1829,  and  Siebold  in 
1816,  followed  essentially  the  same  plan  of  operating.  Dr.  W.  Tyler 
Smith,  of  London,  as  late  as  June,  1861,  adopted  the  method,  and  in 
consequence  of  his  connection  with  giving  it  prominence,  the  plan  of 
practice  is  generally  associated  in  England  Avith  his  name. 

The  pedicle  has  also  been  ligated  by  means  of  carbolized  catgut, 
■which  has  been  recommended  not  only  on  account  of  its  antiseptic 
properties,  but  from  the  fact  that  it  is  rapidly  absorbed  and  Avill  dis- 
appear Avithin  a  few  days.  But  in  this  property  lies  the  danger  from 
its  use,  since  death  has  occurred  in  consequence  of  hemorrhage  Avhere 
the  ligature  has  been  absorbed  before  the  vessels  have  become  oblite- 
rated. This  material  cannot  be  tied  in  so  compact  a  knot  as  silk, 
and  has  no  advantage,  for  the  silk  also  in  time  disappears. 

The  clamp  was  first  adopted  by  Mr.  J.  Hutchinson,  of  London,  in 
1858,  and  his  first  instrument  Avas  the  carpenter's  caliper  compasses, 
which  he  afterwards  improved  by  removing  the  handles.  This  instru- 
ment Avas  at  one  time  the  favorite  means  for  securing  the  pedicle,  but 
it  is  now  seldom  employed.  It  has,  hoAvever,  always  been  the 
favorite  means  used  by  Mr.  Spencer  Wells,  and  the  endorsement  of 
the  value  of  the  instrument  by  one  Avho  has  already  removed  more 
than  nine  hundred  ovarian  tumors  demands  for  it  more  than  a  pass- 
ing; notice. 


82-1  GENERAL    DETAILS    IN    OVARIOTOMY. 

There  are  two  great  advantages  in  the  use  of  the  instrument — bleed- 
ing from  the  pedicle  cannot  take  place  without  being  detected,  and 
no  foreign  body  in  connection  with  the  pedicle  is  left  within  the 
abdominal  cavity.  On  the  other  hand,  unless  the  pedicle  be  a  long 
one,  the  patient  suffers  in  consequence  of  the  traction  exerted  when 
the  abdomen  becomes  distended  by  flatus.  To  this  irritation  can  be 
traced  the  occurrence  of  peritonitis,  as  I  have  frequently  thought. 
The  objection  has  been  advanced  that  this  binding  down  of  the  uterus 
would  have  a  bad  result  in  a  future  pregnancy.  This,  however,  can- 
not be  a  permanent  condition,  for  I  have  often  seen  pregnancy  advance 
without  causing  any  apparent  traction  to  be  exerted  on  the  uterus. 
It  has  also  been  held  that  there  is  a  danger  of  the  intestines  becoming: 
strangulated  by  this  band. 

Mr.  Wells  has  modified,  from  time  to  time,  the  shape  of  the  clamp, 
but  Fig.  124  shows  the  one  at  present  used  by  him,  from  which  the 

Fig.  124. 


WeUs's  clamp  for  the  pedicle. 

handles  can  be  detached,  leaving  but  a  ring  around  the  stump  of  the 
pedicle.  Koeberld  also  uses  a  circular  constrictor,  or  clamp,  which 
acts  very  much  on  the  same  principle  as  the  one  used  by  Mr.  Wells. 

The  instruments  chiefly  used  in  this  country  are  Wells's,  Thomas's, 
Dawson's,- and  Atlee's  clamps,  each  having  some  special  feature  to 
recommend  it.     I  prefer  that  of  Dr.  Thomas. 

The  use  of  the  actual  cautery  at  a  red  heat,  for  dividing  the  pedicle, 
was  first  practised  by  Mr.  Baker  Brown,  of  London;  although  to  Mr. 
John  Clay,  of  Birmingham,  is  due  the  credit  of  the  conception,  since 


SECURING    THE    PEDICLE. 


825 


he  first  employed  the  method  for  dividing  adhesions.     The  practice 
is  not  noAV  employed  as  formerly,  and,  to-day,  it  is  chiefly  advocated 


Fifr.  125. 


Thomas's  clamp. 


by  Mr.  Keith,  of  Edinburg,  Prof.  White,  of  Buffalo,  and,  I  believe, 
by  Dr.  Sims.     As  Mr.  Keith  has  been  successful  in  saving  a  larger 


Fig.  126. 


Dawson's  clamp. 

proportion  of  his  cases  than  any  other  .operator  in  the  world,  this 
special  mode  of  practice  becomes  entitled  to  a  value  which  it  would 
not  otherwise  possess.  Mr.  Baker  Brown  was  obliged  to  resort 
frequently  to  the  use  of  the  ligature,  although  to  the  cautery  was 
given  the  credit  of  controlling  the  bleeding.  "What  Mr.  Keith's  prac- 
tice is  in  regard  to  the  additional  use  of  ligatures,  I  do  not  kuoAV. 
From  a  somewhat  limited  experience  of  the  cautery  I  must  confess  to 
a  feeling  of  mistrust  as  to  its  safety.  But  if  the  precaution  be  taken 
to  tie  separately  the  larger  vessels,  I  believe  that  in  many  cases  the 
use  of  the  cautery  for  dividing  the  pedicle  would  prove  an  excellent 
mode  of  practice. 

In  the  United  States  those  who  had  operated  the  greater  number 


826 


GENERAL    DETAILS    IN    OVARIOTOMY. 


of  times  were  divided  between  the  use  of  the  ligature  and  the  clamp. 
The  late  Dr.  Atlee,  who  removed  a  larger  number  of  ovarian  tumors 
than  any  other  operator  in  this  country,  almost  always  used  the 
clamp;   Dr.  Peaslee,  always  the  ligature;   and,  I  believe,  also  Dr. 


Fig.  127. 


Storer'a  clamp  shield. 


Kimball,  of  Lowell.  Dr.  Thomas  has  a  decided  preference  for  tlie 
clamp,  and  Prof.  White  is  tlie  only  ouc  known  to  me  now,  in  this 
country,  who  advocates  the  use  of  the  cautery. 


SECURING    THE    PEDICLE.  827 

Whenever  the  cautery  is  employed,  its  value  Avill  rest  upon  the  use 
of  a  temperature  so  far  below  white  heat  that  the  tissues  can  only  be 
separated  slowly,  so  that  they  may  be  changed  in  character  for  some 
distance  beyond  the  actual  contact  of  the  iron.  There  will  be  no 
fear  of  sloughing,  but  this  will  alone  insure  the  destruction  of  all  but 
the  largest  sized  bloodvessels,  which  must  be  ligated,  as  a  rule. 

In  connection  with  the  subject  of  securing  the  pedicle,  reference 
must  be  made  to  Dr.  H.  R.  Storer's  "  clamp  shield,"  which  is  an 
excellent  instrument  to  be  used  as  a  temporary  clamp.  For  the  re- 
moval of  the  uterus,  or  for  securing  tissues  deep  in  the  pelvis,  we 
have  no  other  device  so  well  adapted. 

There  are  certain  conditions,  viz.,  absence  of  the  pedicle,  too  short 
a  pedicle,  and  the  existence  of  adhesions  close  to  the  attachment, 
which  render  it  advisable  to  enucleate  the  tumor,  as  suo;o:ested^  and 
first  practised  by  Dr.  J.  F.  Miner,  of  Buffalo.  In  a  case  where  the 
cyst  was  generally  adherent  he  succeeded  in  sepai-ating  so  extensively 
the  layers  of  the  cyst  wall  as  to  free  the  tumor. 

It  is  recommended  to  belt  the  tumor  by  a  somewhat  superficial  in- 
cision at  a  distance  from  the  pedicle,  and  then  attempt  to  separate  the 
tissues  so  as  to  loosen  the  tumor  from  its  connection  with  the  pedicle 
until  it  becomes  free. 

Dr.  Miner  states  that  "  the  pedicle  was  large  and  extended  over  a 
wide  surface,  but  by  gentle  and  patient  efforts,  it  was  separated  from 
its  entire  attachment  to  the  tumor,  and  the  immense  growth  removed 
without  the  ligation  of  a  single  vessel.  The  terminal  branches  of  the 
vessels  of  the  pedicle  gave  out  no  more  blood  than  issued  from  the 
vessels  of  the  attachment  elsewhere,  and  there  appeared  no  more  occa- 
sion for  ligature  here  than  elsewhere." 

Dr.  Miner  has  practised  this  method  in  a  number  of  cases,  as  have 
Prof.  James  P.  White,  of  Buffalo,  and  others.  I  have  found,  in  some 
cases,  the  cyst  walls  in  such  a  condition  that  no  such  separation  could 
be  made,  while  in  others  it  could  be  accomplished  with  facility.  I 
have  never  had  a  case  in  which  it  was  necessary  for  me  to  follow  this 
plan  of  enucleation. 

During  the  meeting  of  the  Obstetrical  Section  of  the  Am.  Medical 
Association,  in  1876,  Dr.  Alex.  Dunlap,  of  Springfield,  Ohio,  pro- 
posed^  what  he  called  a  division  of  the  pedicle. 

The  tumor  is  first  to  be  freed  from  all  adhesions  and  lifted  from 


'  Buffalo  Med.  and  Surg.  Journ.,  June,  1SG9. 
2  Medical  Record,  July  8,  1876. 


828  GENERAL  DETAILS  IN  OVARIOTOMY. 

its  bed,  and  the  pedicle  secured  in  a  temporary  manner  to  prevent 
bleeding.  Then  a  cut  is  to  be  made  around  the  tumor,  about  half 
■R-ay  through,  and  at  such  a  distance  that  enough  of  the  peritoneum 
may  be  saved  to  form  a  long  pedicle.  After  doing  this,  the  next  step 
is  to  enucleate  the  tumor  in  the  same  manner  as  practised  by  Dr. 
Miner,  of  Buffalo.  This  leaves  the  bottom  of  the  cup- shaped  wound 
restincr  on  the  broad  ligament  of  the  uterus.  He  directed  that,  after 
securing  the  vessels,  from  five  to  six  long  loops  of  silk  should  be  passed 
through  the  cut  edge  of  the  peritoneum,  at  equal  distances.  Then  a 
curved  metal  speculum  was  to  be  introduced  into  the  vagina  to  one 
side  of  the  uterus,  but  never  in  front  or  behind  it,  and  as  the  instru- 
ment was  being  pushed  up  against  the  bottom  of  the  wound,  a  small 
opening  was  to  be  made. 

Through  this  opening  were  to  be  passed  into  the  vagina  all  the  silk 
loops  from  the  edge  of  the  peritoneum,  and  the  ligatures  for  securing 
the  vessels,  down  through  the  speculum  to  the  vaginal  outlet.  Then 
as  traction  was  made  on  these  loops,  the  detached  peritoneum  became 
inverted,  and  thus  the  raw  surfaces  were  brought  together  in  close 
contact. 

By  this  method  no  discharge  from  the  site  of  the  pedicle  could  enter 
the  peritoneal  cavity,  and  the  ligatures  after  becoming  detached  could 
be  withdrawn  through  the  vagina.  Dr.  Dunlap  suggested  that  a 
similar  plan  might  be  followed  in  the  removal  of  fibroid  tumors. 

This  plan  resembles  in  many  respects  the  one  adopted  by  Prof. 
Freund,  of  Breslau,  by  which  he  removed  in  five  instances  the  uterus 
for  cancer,  two  cases  surviving  the  operation.  I  am  unable  to  deter- 
mine to  whom  the  credit  of  priority  is  due  for  this  method  of  inverting 
the  peritoneum,  and  thus  bringing  together  the  denuded  surfaces,  and 
passing  the  ligatures  through  the  vagina. 

Prof.  Freund  also  recommends  the  procedure  for  the  removal  of 
fibrous  tumors.  We  will  not  enter  into  the  merits  of  this  operation 
for  the  removal  of  cancer  of  the  uterus,  or  more  than  question  if  any 
permanent  advantage,  in  this  condition,  can  possibly  be  derived.  But 
where  a  case  has  proved  to  be  a  fibrous  tumor  of  the  uterus,  instead 
of  an  ovarian  tumor,  and  it  becomes  necessary  to  complete  the  opera- 
tion by  removing  the  organ,  the  method  may  be  followed  with  advan- 
tage, and  the  chances  of  recovery  would  be,  in  all  probability,  not 
altogether  unfavorable. 

After  a  temporary  ligature  has  been  passed  around  the  tumor  to 
control  the  bleeding,  it  is  recommended  to  tie  the  vessels  in  the  broad 
ligament  on  each  side.     Then  the  mass  may  be  removed  and  the  stump 


REMOVAL    OF    THE    UTERUS    FOR    FIBROIDS.  829 

of  the  uterus  separated  from  the  connective  tissue  about  it,  and  freed 
from  its  attachment  to  the  vagina.  When  this  has  been  done  the 
surfaces  are  all  doubled  on  themselves,  and  drawn  down  by  the  liga- 
tures to  the  opening  into  the  vagina. 

Then,  to  cut  off  all  communication  with  the  abdominal  cavity  above, 
the  edges  of  the  peritoneum  and  other  tissues,  are  brought  together 
by  a  whip-stitch  across  the  opening  into  the  vagina. 

A  more  extended  description  of  this  operation,  with  several  dia- 
grams, will  be  found  in  Mr.  Wells's  lecture,  published  in  the  British 
3Iedieal  'Journal,  July  27,  1878. 


830  ABDOMINAL    OVARIOTOMY. 


CHAPTEE    XLIII. 

ABDOMINAL  OVARIOTOMY. 

Steps  of  the  operation — After-treatment  :  antiseptic  dressings  ;  closing  of  the  in- 
cision ;  reduction  of  temperature  (quinine,  cold  -tvater  applications,  "fever 
cot"). 

Steps  of  the  Operation. — The  incision  in  the  ahdominal  walls  has 
sometimes  been  made  through  the  muscles  directly  over  the  seat  of  the 
diseased  ovary,  but  there  seems  to  be  no  special  advantage  in  this, 
and  now  it  is  almost  always  made  in  the  linea  alba.  The  location  of 
this  line  can  be  easily  traced  by  the  eye  from  the  symphysis  pubis  to 
the  umbilicus,  and  frequently,  in  ovarian  disease,  a  dark  line  in  the 
skin  marks  the  course  of  the  linea  alba  beneath. 

The  first  incision  is  to  be  made  in  this  line,  between  the  two  recti 
muscles,  about  an  equal  distance  from  the  umbilicus  at  one  end,  and 
from  the  pubes  at  the  other.  After  cutting  through  the  skin,  the 
connective  tissue,  and  a  greater  or  less  thickness  of  fat,  the  abdominal 
fascia  will  be  brought  into  view,  and  this  must  be  laid  open  on  a  grooved 
director,  as  the  peritoneum  is  immediately  below  it.  This  in  turn  should 
be  carefully  opened  by  catching  it  up  with  a  pair  of  forceps,  snipping 
a  small  opening  for  the  introduction  of  the  grooved  director,  and  then 
dividing  it  with  the  scalpel  or  scissors.  The  incision  at  first  should 
not  be  more  than  three  or  four  inches  in  length,  and  the  progress  of 
the  operation  should  be  slow,  so  that  each  bleeding  vessel  may  be 
either  tied,  or  secured  by  a  pair  of  forceps  before  opening  the  perito- 
neal cavity.  As  soon  as  the  surface  of  the  sac  has  been  exposed,  it 
will  be  readily  recognized,  while  yet  moist,  as  has  been  stated,  from 
its  pecrdiar  pearl-like  hue.  Whenever  it  is  dark  and  vascular  from 
beino-  covered  with  unusually  large  vessels,  this  is  generally  indica- 
tive of  a  fibro-cystic  tumor  of  the  uterus. 

When  the  sac  has  become  firmly  adherent  to  the  abdominal  walls, 
it  is  sometimes  impossible  to  recognize  the  peritoneum.  In  the  attempt 
to  separate  the  supposed  adhesions,  this  membrane  may  be  extensively 
torn  ofi'  from  the  muscular  tissue,  and  there  may  be  considerable 
hemorrhage  before  the  true  condition  is  detected.  This  may  lead  to 
much  trouble  afterwards,  and  to  avoid  it  we  must  proceed  with  care 


EMPTYING    THE    TUMOR. 


831 


until  the  tumor  has  been  reached,  and  even  if  it  be  punctured  by 
accident  it  can  be  safely  emptied  before  the  adhesions  are  broken  up. 

Under  ordinary  circumstances  it  is  desirable  to  have  some  idea  in 
regard  to  the  extent  of  adhesions  before  evacuating  the  contents  of  the 
tumor.  This  is  ascertained  by  introducing,  through  the  small  abdomi- 
nal incision,  a  large  steel  sound,  as  made  for  the  male  urethra,  or  a 
block  tin  rod  (which  I  prefer)^  the  instrument  being  carefully  passed 
in  every  direction  over  the  surface  of  the  tumor.  If  it  is  evident  that 
adhesions  exist  to  any  extent,  it  -will  be  necessary  to  introduce  between 
the  tumor  and  abdominal  walls,  two  fingers  as  a  guide,  and  with  a 
pair  of  scissors  extend  the  incision,  passing  upwards  to  the  left  of  the 
umbilicus,  or  beyond,  if  necessary,  and  downwards  to  the  pubes,  care 
being  taken  to  avoid  injuring  the  bladder. 

Trocars  of  various  forms  have  been  devised  for  drawing  off  the  con- 
Fig.  128.  : 


Wells's  trocar. 


tents  of  the  sac.     Wells's  trocar  is  much  used.    It  has  an  arrangement 
for  seizing  the  walls  of  the  cyst  and  drawing  it  out  as  it  becomes 

Fig.  129. 


Emmei's  trocar. 


emptied.     Fitch's  "  dome  trocar"  has  been  enlarged  for  this  purpose  ; 
its  principle  admirably  fits  it  for  tapping  the  cavity  of  the  pleura  or 


832  ABDOMINAL    OVARIOTOMY. 

pericardium  without  wouucTing  the  lungs  or  heart,  but  it  possesses  no 
special  advantage  for  emptying  an  ovarian  cyst  which  is  exposed  to 
view.  I  prefer  a  simple  curved  trocar  and  canula  about  five  or  six 
inches  in  length,  which  I  had  made  many  years  ago,  and  still  continue 
to  use  (see  Fig.  129). 

The  operator  will  select  some  point  free  from  bloodvessels,  in  the 
largest  sac  (if  there  be  more  than  one),  through  which  to  plunge  the 
trocar  and  canula.  Unless  the  tumor  is  free  from  adhesion,  so  that  it 
can  be  drawn  out  to  prevent  the  escape  of  fluid  into  the  abdominal  cav- 
ity, it  should  be  tapped  with  the  patient  on  her  side,  as  first  recom- 
mended by  Mr.  Wells.  The  patient  can  be  turned  well  over  on  the 
side,  and  be  thus  held  by  the  assistants,  while  the  operator  gradually 
draws  out  the  sac  by  means  of  any  strong  forceps  or  vulsellum  con- 
structed for  the  purpose.  A  linen  cloth  must  be  placed  under  the 
tumor  and  over  the  lower  edge  of  the  wound,  to  receive  any  cystic 
fluid  which  might  by  accident  escape  alongside  of  the  canula,  other- 
wise it  may  enter  the  abdominal  cavity.  As  the  abdominal  walls  be- 
come more  relaxed,  the  upper  edge  of  the  incision  should  also  be 
covered  by  a  linen  cloth  to  protect  the  parts,  and  to  keep  the  hand  of 
the  assistant  from  coming  in  direct  contact  with  the  intestines,  which 
are  liable  to  protrude. 

The  most  frequent  seat  of  the  adhesions  is  to  the  abdominal  walls, 
and  next  to  the  omentum,  covering  the  anterior  surface  of  the  cyst. 
They  may  be  found  in  both  places. 

Great  care  and  skill  are  required  to  separate  the  adhesions  between 
the  tumor  and  the  abdominal  walls.  This  separation  must  be  made, 
as  has  been  stated,  by  tearing  off  the  adhesions  from  the  surface  of  the 
tumor,  and  never  from  the  abdominal  wall,  as  this  would  leave  the 
muscular  tissue  exposed  without  any  peritoneal  covering,  which  would 
delay  and  complicate  the  progress  of  the  operation.  But  when  the 
adhesions  are  separated  from  the  surface  of  the  tumor,  it  rarely  hap- 
pens that  any  large  bloodvessels  are  lacerated,  and  what  capillaries 
are  torn  will  promptly  close  up. 

If  the  omentum,  as  indicated  by  its  appearance,  is  found  to  be  ad- 
herent to  the  tumor  at  the  abdominal  opening,  more  care  must  be  ex- 
ercised in  making  traction,  through  fear  of  tearing  the  connection  of 
the  omentum  with  the  intestine  beyond.  It  is  not  necessary  to  delay 
for  the  purpose  of  attempting  to  separate  the  omentum  from  the  surface 
of  the  tumor,  but  just  beyond  the  adhesions  two  ligatures  may  be 
placed,  an  inch  apart,  around  the  mass,  which  may  then  be  divided 
between  the  ligatures  with  a  pair  of  scissors.     This  will  prevent  any 


BREAKING    UP    ADHESIONS.  833 

bleeding  from  the  tumor,  and  the  ligature  from  the  end  attached  to 
the  omentum  should  be  placed  in  charge  of  an  assistant  while  the 
stump  is  temporarily  returned  to  the  abdominal  cavity. 

Adhesions  are  sometimes  formed  with  the  under  surface  of  the  liver, 
and  to  the  stomach  and  small  intestines.  If  these  are  carelessly 
broken  up,  the  substance  of  the  viscera  may  be  torn,  and  fatal  results 
follow.  When  slight  they  may  be  separated  from  the  surface  of  the 
tumor ;  but  the  safest  plan  is  to  cut  around  the  adhesions  so  as  to 
leave  the  adherent  part  of  the  cyst  wall  intact,  and  then  carefully 
str'p  off  the  portion  of  lining  membrane.  If  a  vessel  be  divided  it 
must  be  secured  with  a  fine  silk  ligature. 

Dr.  Peaslee  states  that  adhesions  to  the  stomach  are  never  found, 
although  Kiwisch  admits  them.  After  Dr.  Peaslee  wrote  his  Avork, 
however,  he  was  present  at  an  operation  begun  by  me  in  the  Woman's 
Hospital,  in  which  both  the  stomach  and  transverse  colon  were  adhe- 
rent to  the  surface  of  the  tumor,  as  I  have  described  when  treating  of 
the  injections  of  iodine  into  the  sac. 

After  one  cyst  has  been  emptied,  the  hand  may  be  introduced  into 
it  for  the  purpose  of  breaking  down  the  partition  walls,  so  that  the 
contents  of  all  the  cysts  may  escape  by  one  common  outlet;  or  each 
cyst  may,  in  turn,  be  emptied  by  a  trocar  as  it  presents.  When  the 
tumor  has  been  thus  sufficiently  reduced  in  size  to  be  draAvn  out  of 
the  abdominal  cavity,  it  should  be  wrapped  up  in  a  towel  to  preserve 
its  warmth  and  circulation  until  the  pedicle  can  be  divided.  The 
patient  is  then  to  be  turned  on  her  back,  the  abdominal  incision  held 
open,  so  that  the  small  intestines  and  the  parts  about  the  pedicle  may 
be  covered  by  pieces  of  linen  cloth  wrung  out  of  warm  water  to 
which  carbolic  acid  has  been  added.  This  will  protect  the  intestines 
from  cold  and  from  the  continued  action  of  the  spray,  and  will  absorb 
any  blood  which  oozes  from  the  w^alls,  or  from  the  pedicle  after  it 
has  been  divided. 

A  clamp  or  a  strong  cord  should  next  be  passed  around  the  pedicle, 
close  to  the  tumor,  for  a  temporary  ligature,  and  the  mass  divided 
with  a  pair  of  scissors  at  a  safe  distance  from  the  constricted  point. 
As  the  tumor  is  held  up  by  the  assistant,  that  the  cord  may  be 
applied,  he  should  not  make  any  traction. 

Case  LXI. — I  lost  a  patient  in  the  Woman's  Hospital  for  Avant  of 
care  in  this  respect.  The  operation  had  been  a  very  satisfactory  one, 
and  I  did  not  know  that  undue  traction  was  made  by  my  assistant  as 
I  applied  the  ligature.  Shortly  after  the  patient  recovered  from  the 
eflFects  of  the  ether,  symptoms  of  loss  of  blood  presented  themselves 
53 


834  ABDOMINAL    OVARIOTOMY. 

with  increasing  urgency.  The  cause  was  so  obvious  that  I  opened 
the  lower  angle  of  the  Avound,  expecting  to  find  hemorrhage  from  the 
stump  of  the  pedicle,  but  on  passing  a  sponge  probang  down  into 
Douglas's  cul-de-sac  it  was  evident  that  the  cavity  was  even  unusually 
free  from  bloody  serum.  I  was  unable  to  account  for  the  condition, 
and  death  took  place  in  a  few  hours.  A  post-mortem  examination 
disclosed  a  thrombus  in  the  connective  tissue  under  the  fascia,  which 
dissected  up  the  pelvic  tissue  and  extended  beyond  the  left  kidney. 
Some  vessel  in  the  cellular  tissue  under  the  pedicle  had  been  ruptured, 
several  quarts  of  blood  were  lost,  causing  intense  suifering  to  the 
patient  by  pressure  on  the  ureter  and  kidney,  and  from  which  she 
could  not  be  relieved  even  when  stupefied  Avith  opium. 

After  cutting  away  the  tumor  and  ascertaining  that  there  is  no 
bleeding  from  the  stump,  it  may  be  temporarily  dropped  back  into 
the  cavity,  the  long  ends  of  the  ligature  being  held  by  an  assistant. 
The  tumor  being  out  of  the  way,  a  careful  inspection  must  be  made 
to  ascertain  that  no  bleeding  is  taking  place  from  the  abdominal  walls 
or  from  vessels  which  may  have  been  ligated.  Fresh  linen  cloths, 
which  have  been  wet  in  the  warm  solution  of  carbolic  acid  and  wrung 
out  nearly  dry,  may  be  again  spread  out  over  the  small  intestines  to 
protect  them  from  the  chilling  effect  of  the  spray,  and  those  over  the 
edges  of  the  incision  and  peritoneum  on  the  abdominal  wall,  may  be 
changed. 

If  the  clothing  or  covering  of  the  patient  should  have  become  wet 
from  the  escape  of  the  contents  from  the  tumor,  these  must  be  re- 
moved or  rolled  up,  and  dry  warm  towels  laid  next  to  the  skin. 

The  pedicle  may  now  be  finally  secured.  If  a  clamp  is  to  be  used, 
the  temporary  one,  which  may  have  been  applied  instead  of  a  ligature, 
need  not  necessarily  be  removed.  If  the  pedicle  is  to  be  ligated,  an 
assistant  must  lift  up  the  free  end  of  the  stump  with  a  tenaculum  or 
by  the  clamp,  if  one  has  been  applied,  making  as  little  traction  as 
possible.  As  the  stump  is  held  up,  the  operator  will  be  able  to  select 
a  point  free  from  bloodvessels  through  which  to  pass  a  needle  carrying 
a  double  thread  forming  a  loop.  By  this  loop  the  silk  ligature  is  to 
be  drawn  through  in  two  portions  of  equal  length.  Unless  the  pedicle 
is  of  unusual  thickness,  it  will  be  sufficient  to  tie  it  in  two  sections. 
After  cutting  the  silk  so  as  to  make  two  ligatures,  one  must  be  passed 
around  the  other  so  that  when  they  are  tied  they  Avill  be  linked  to- 
gether, and  not  lie  independent  of  each  other.  If  this  is  not  done 
the  pedicle  will  be  apt  to  split  from  the  point  at  which  the  ligatures 
Avere  passed  and  give  rise  to  hemorrhage.  The  ends  of  the  ligatures 
should  be  tied  at  first  only  in  a  half-knot  on  each  side,  but  securely 


CLEANSING    THE    PERITONEAL    CAVITY.  835 

enough  to  compress  the  tissues  as  much  as  the  strength  of  the  silk 
■will  permit.  Then  as  the  stiunp  of  the  pedicle  is  held  up  with  a 
tenaculum  in  the  hands  of  an  assistant,  the  temporary  ligature  should 
be  cut  aAvay  or  the  clamp  loosened.  But  before  this  is  done  a  cloth 
or  sponge  must  be  placed  about  the  pedicle  to  absorb  what  blood  may 
escape.  The  quantity  of  blood  escaping  Avill  be  small  if  a  half-knot 
has  been  already  made  on  each  side,  for  it  will  require  but  a  second 
of  time  for  the  operator  to  tighten  the  first  half,  and  then  complete 
what  is  called  a  square  knot  by  the  addition  of  a  half-knot  afterwards. 
It  is  always  w-ell  thus  to  loosen  the  temporary  ligature  before  securing 
the  permanent  one,  so  as  to  admit  of  the  escape  of  blood  included 
betw'een  the  two  ligatures,  or  hemorrhage  may  afterwards  occur. 
Until  the  condition  of  the  other  ovary  has  been  examined,  an  assistant 
will  continue  to  hold  the  end  of  the  pedicle  with  a  tenaculum,  and 
never  by  the  ends  of  the  ligatures.  If  the  other  ovary  be  found 
diseased,  a  double  ligature  must  be  passed  through  its  pedicle  in  the 
manner  just  described,  and  it  must  be  also  removed.  The  ends  of 
all  the  ligatures  are  to  be  cut  oft"  as  close  to  the  knot  as  can  be  done 
with  safety,  and  the  stump  of  the  pedicle  then  trimmed  of  all  ragged 
portions  not  nearer  to  the  ligatures  than  one  inch.  The  ends  of  the 
remaininui;  lio;atures  in  charsfe  of  the  assistant  are  in  turn  to  be  cut 
oif  close,  after  it  has  been  seen  that  all  bleeding  has  been  arrested  by 
them.  All  blood-clots  are  to  be  removed,  and  Douglas's  cul-de-sac 
emptied  of  the  fluid  which  may  have  gravitated  into  it.  To  do  this 
the  left  hand  is  to  be  passed  down  close  to  the  uterus,  Avith  the  palm 
towards  the  intestines,  to  push  them  back,  Avhen  the  sponge  probang 
can  be  easily  passed  to  the  bottom  of  the  cavity.  After  the  cul-de- 
sac  has  been  emptied  a  fine,  clean,  surgical  sponge,  with  a  string 
attached,  may  be  introduced  to  the  bottom  of  the  pouch  and  left 
there,  with  the  string  outside  in  charge  of  an  assistant.  The  linen 
cloths  which  had  been  placed  over  the  small  intestines  should  now  be 
changed  for  a  fresh  one,  and  those  over  the  edges  of  the  abdominal 
incision  are  to  be  removed  for  the  purpose  of  closing  the  cavity . 

I  have  met  with  several  instances  of  umbilical  hernia,  in  connection 
with  ovarian  tumors.  The  first  instance  coming  under  my  observa- 
tion was  seen  by  the  late  Dr.  Peaslee  in  consultation,  in  1868,  where 
the  ring  was  dilated  sufficiently  to  admit  two  fingers.  In  this  case, 
as  in  the  others,  I  extended  the  abdominal  section  to  one  side  and  re- 
moved the  Avhole  umbilical  ring,  with  a  pair  of  scissors  uniting  the 
entire  incision  in  the  abdominal  wall  in  one  common  line. 

Metallic  sutures  are  now  generally  employed  for  this  purpose.     Mr. 


836  ABDOMINAL    OVAKIOTOMY. 

Wells,  however,  uses  silk.  These  sutures  may  be  introduced  by  one 
of  three  methods.  The  most  common  is  by  the  aid  of  an  awl  shaped 
instrument,  like  Dr.  Skene's  straight  needle,  or  the  curved  one  of 
Dr.  Peaslee,  for  closing  a  ruptured  perineum. 

Fi^.  130. 


G-TlliNlANN&CO. 

/ifULARGED    View. 
Skene's  needle  for  ruptured  perineum. 

Near  the  point  of  the  instrument  is  an  eye  through  which  a  loop 
of  thread  is  inserted.  While  the  instrument  is  being  passed  through 
the  tissues  the  two  ends  of  the  loop  are  to  be  grasped  with  the  handle 
and  held  until  the  eye,  Aviththe  thread,  has  passed  through  both  flaps. 
After  having  passed  through  one  flap,  the  other  is  to  be  adjusted  in  proper 
relation  to  the  point  of  the  instrument,  to  secure  a  perfect  coaptation. 
The  wire  is  now  to  be  attached  to  the  loop  of  the  thread  and  pulled 
through  the  two  flaps  as  the  needle  is  withdrawn. 

I  am  in  the  habit  of  using  for  this  purpose  a  straight  thick  sewing 
needle,  about  two  inches  long,  armed  with  a  loop  of  thread  of  a  suffi- 
cient length,  to  which  the  wire  has  been  already  attached,  and  the 
needle  is  passed  by  means  of  the  needle  forceps  in  the  following  manner : 
The  operator  catches  up  one  flap  between  his  thumb  and  fingers, 
and  forces  the  needle  through  the  tissues,  making  the  point  of  exit 
about  an  inch  from  the  margin. 

Then  the  opposite  lip  of  the  incision  is  seized  in  the  same  manner, 
and  turned  out  a  little,  so  as  to  expose  the  peritoneal  surface,  that  the 
point  of  the  needle  may  be  introduced  at  a  distance  corresponding  to 
its  exit  from  the  other  flap. 

It  is  advisable  to  bring  together  in  this  manner  a  broad  strip  of  the 
peritoneum,  Avhenever  it  can  be  done.  The  peritoneal  surfaces  will 
adliere  in  a  few  hours,  Avhen  held  in  close  contact,  and  prevent  pus, 
or  other  fluid,  passing  from  the  wound  into  the  abdominal  cavity.  The 
sutures  are  to  be  introduced  somewhat  in  reference  to  the  thickness 
of  the  parietes,  for  should  they  be  thick,  unfortunately  only  a  limited 
portion  of  the  peritoneal  surfaces  can  be  brought  up  in  contact  by 
them.  The  points  at  which  the  sutures  emerge  from  the  flaps  should 
lie  nearer  the  edges  of  the  incision  on  the  skin  surface  than  they  do 
on  the  peritoneal  surface,  because  this  secures  a  better  coaptation. 


CLOSING    THE    INCISION.  837 

I  have  sometimes  attached  a  needle  to  each  end  of  a  piece  of  silver 
wire  and  passed  them  through  the  tissues  from  ^vithin  outwards. 

Wlien  the  operator  has  introduced  a  suture  through  the  flaps  it  is  to 
be  transferred  to  the  assistant,  who  should  regulate  the  proper  length, 
and  bring  together  the  sides  of  the  incision,  by  a  twist  or  two  of  the 
wire,  while  the  next  suture  is  being  passed.  The  sutures  are  to  be 
introduced  from  above  downward,  a  distance  of  half  an  inch  apart, 
mitil  all  have  been  passed  ;  but  a  sufficient  number  are  to  be  left  un- 
twisted at  the  lower  angle  of  the  wound,  so  as  to  allow  of  the  removal 
of  the  linen  cloth  spread  over  the  small  intestines,  and  of  the  sponge 
which  had  been  left  in  Douglas's  pouch.  It  will  be  necessary  to  pass 
several  fingers  between  the  flaps,  down  to  the  sponge,  to  keep  back  the 
intestines  while  the  sponge  is  being  removed.  After  its  removal  a 
sponge  probang  should  be  introduced  before  withdrawing  the  fingers, 
to  insure  that  the  cul-de-sac  has  been  thoroughly  emptied. 

If  the  pedicle  has  been  secured  by  a  clamp  it  must  now  be  placed 
at  the  lower  angle  of  the  wound  to  be  held  there  until  all  sutures  have 
been  secured.  Whenever  the  adhesions  have  been  extensive  it  is 
advisable  to  introduce  a  draina2:e  tube  to  the  bottom  of  Douglas's  cul- 
de-sac  before  the  fingers  are  withdrawal.  The  assistant  should  hold 
it  in  the  lower  third  of  the  incision,  until  all  the  sutures  have  been 
secured.  I  always  require  the  third  assistant  to  continue  the  lateral 
pressure  with  the  palms  of  his  hands  spread  out  over  the  sides  of  the 
abdomen,  until  the  bandage  is  to  be  applied,  as  this  controls  the 
oozing  by  keeping  the  side  of  the  abdominal  wall  in  close  contact  with 
the  intestines.  Whenever  the  abdominal  parietes  are  much  relaxed, 
an  assistant  can  keep  the  peritoneal  surfaces  bordering  on  the  incision 
in  close  contact  during  the  introduction  of  the  sutures.  Another  advan- 
tage of  this  pressure  is  that  it  affords  a  support,  and  closes  the  cavity 
against  the  entrance  into  it  of  blood  from  the  peritoneal  surface,  or 
from  the  punctures  of  the  needles. 

It  is  advisable  to  discontinue  gradually  the  inhalation  of  the  ether 
towards  the  close  of  the  operation,  so  that  the  patient  may  even  be 
somcAvhat  conscious  of  the  introduction  of  the  last  sutures.  The  final 
adjustment  of  the  sutures  will  require  some  care,  that  they  may  not 
prove  a  source  of  irritation.  They  are  to  be  twisted  as  when  used 
internally,  and  after  having  been  bent  over  flat  to  the  surface  of  the 
skin,  in  the  manner  directed  in  the  chapter  on  the  use  of  the  silver 
suture,  their  ends  are  to  be  cut  to  about  half  an  inch  in  length. 

Throughout  the  whole  progress  of  the  operation  the  spray  should 
be  properly  directed,  and  the  open  abdominal  cavity  should  be  at  no 


838  ABDOMTNAL    OVARIOTOMY. 

time  exposed.  AVhen  the  operation  has  been  prolonged,  and  the  spray 
apparatus  is  known  to  be  nearly  empty,  either  of  water  or  alcohol,  the 
instrument  in  reserve  must  be  prepared,  and  be  in  good  working  order 
over  the  wound  before  the  other  is  withdrawn.  If,  for  any  cause, 
there  should  be  an  interrujDtion  in  the  action  of  the  spray,  the  abdomen 
must  be  immediately  covered  with  several  thicknesses  of  the  gauze 
cloth,  Avet  with  the  weakest  solution  of  the  carbolic  acid,  to  be  un- 
covered only  when  the  spray  is  again  in  operation. 

If  there  is  any  advantage  in  the  antiseptic  method,  it  can  only  be 
secured  by  observing  scrupulously  the  minutest  details.  Perhaps  in 
private  pracitice,  and  under  some  other  favorable  circumstances,  there 
may  be  apparently  little  advantage  in  it,  but  in  hospital  practice,  its 
advantages  cannot  be  questioned. 

The  spray  is  to  be  continued  until  the  bandage  has  been  adjusted. 
After  having  sponged  off  the  surface  of  the  abdomen,  a  piece  of 
"  protective,"  about  tAvo  inches  wide,  and  wet  with  the  Aveakest  carbolic 
solution,  is  to  be  laid  directly  over  the  wound,  a  hole  having  been 
made  in  it  for  the  drainage  tube.  Over  this,  and  covering  a  large 
portion  of  the  abdomen,  is  to  be  spread  a  single  thickness  of  the  gauze 
cloth  also  Avet  with  the  same  solution  ;  then  a  sufficient  quantity  of  the 
dry  gauze  cloth  folded  into  about  eight  or  ten  thicknesses,  and  large 
enough  to  reach  from  the  pubes  to  the  ensiform  cartilage,  and  from  one 
crest  of  the  ilium  to  the  other.  Between  the  outer  folds,  a  somewhat 
smaller  piece  of  the  mackintosh  is  to  be  spread  with  the  rubber  surface 
doAA'nward.  Finally,  under  the  patient,  must  be  spread  a  piece  of 
muslin  the  size  of  an  obstetrical  binder,  and  split  up  from  each  end  into 
a  number  of  tails.  These  are  to  cross  over  the  abdomen,  interlacing 
like  a  many-tailed  bandage,  and  the  ends  are  to  be  pinned  so  as  to 
maintain  an  equable  degree  of  pressure.  The  spray  may  noAV  be  dis- 
continued, but  it  Avill  be  necessary  before  completing  the  dressing  to 
stuft'  in  around  the  edges  of  the  bandage,  about  the  pubes  and  ribs,  a 
sufficient  quantity  of  carbolized  jute  to  fill  in  the  spaces.  This  method, 
obtained  from  Dr.  Weir,  is  essentially  the  one  Avhich  Mr.  Lister  has 
adopted  in  general  surgical  practice. 

Mr.  Wells  in  his  third  lecture^  describes  his  mode  of  applying  this 
dressing  in  the  folloAving  manner.  "  The  last  thing  I  have  tried  seems 
to  me  to  ansAver  better  than  anything.  It  is  gauze  saturated  Avith 
thymol,  the  last  substitute  for  carbolic  acid.  Thymol  and  spermaceti 
are  mixed  together.     The  gauze  is  charged  Avith  it,  and  makes  a  very 

>  Brit.  Med.  .Jour.,  July  G,  1878. 


AFTER-TREATMENT.  839 

nice  soft  antiseptic  dressing,  ^vhich  is  simply  put  over  the  united 
Avound.  Eight  or  ten  other  fohls  are  put  over  the  first,  and  then  you 
support  the  -whole  with  strips  of  plaster,  and  the  flannel  bandage 
(lined  with  linen  or  calico  to  lessen  the  irritating  action  of  the  flannel 
on  the  skin  of  the  patient),  and  this  bandage  is  tightly  fastened  over 
the  gauze  Avith  safety  pins." 

"Whenever  it  becomes  necessary  to  disturb  this  dressing,  it  must  be 
changed  under  the  spray,  with  as  much  care  as  was  exercised  during 
the  progress  of  the  operation. 

After-Treatment. — As  a  large  proportion  of  the  deaths  from  ovari- 
otomy are  due  to  shock,  special  attention  should  be  directed  to  bring- 
ing about  a  reaction  immediately  after  the  operation.  Heat  should 
be  applied  to  the  patient's  body,  no  matter  what  the  season  of 
the  year,  and  she  should  be  left  quiet,  in  a  well  ventilated  room,  of 
which  the  temperature  is  to  be  maintained  at  about  65°F.  Very  little 
else  need  be  done  unless  symptoms  of  prostration  should  appear,  when 
it  may  be  necessary  to  give  brandy  hypodermically  or  by  the  rectum 
until  it  can  be  retained  by  the  stomach.  Beef  tea  may  also  be  given 
with  the  brandy  by  the  rectum  if  indicated,  a  towel  being  held  by  the 
nurse  firmly  against  the  anus  to  prevent  its  expulsion  should  a  par- 
oxysm of  vomiting  come  on.  Hypodermic  stimulation  is,  however,  to 
be  resorted  to  only  Avhen  immediate  effects  are  demanded,  as  it  not 
infrequently  gives  rise  to  abscesses. 

To  allay  the  distressing  vomiting  which  sometimes  continues  after 
the  ether  is  withdrawn,  a  mustard  plaster  should  be  placed  over  the 
stomach  before  the  patient  becomes  conscious.  Small  fragments  of 
ice  may  be  given,  and  perhaps  a  little  carbolic  acid  water  or  cham- 
pagne if  needed.  Mr.  Keith  recommends  the  sipping  of  hot  water, 
and  it  is  sometimes  very  efficient.  If  the  nausea  and  vomiting  are 
not  quieted  within  a  reasonable  time,  it  may  become  necessary  to 
administer  a  hypodermic  injection  of  morphia  to  prevent  too  great  a 
loss  of  strength. 

After  reaction  has  been  established,  the  stomach  should  remain  at 
rest  for  two  or  three  days,  having  nothing  put  into  it  beyond  a  little 
cracked  ice,  and  occasionally  a  spoonful  of  milk,  with  as  much  lime 
water.  All  the  nourishment  should  be  given  by  the  rectum,  and  with 
as  little  disturbance  as  possible.  Mr.  Keith  gives  no  food  at  all  until 
flatus  has  begun  to  escape  from  the  anus ;  and  Dr.  Charles  Clay,  of 
Manchester,  advises  that  no  solid  food  be  given  until  the  patient  asks 
for  it. 

At  any  time  after  the  first  twenty-four  hours,  and  within  a  week 


840  ABDOMIXAL    OVARIOTOMY. 

from  the  time  of  the  operation,  there  may  be  an  elevation  of  tempera- 
ture and  an  increase  of  pulse.  Following  these,  if  the  progress  is 
unfavorable,  there  may  occur  vomiting,  pain  over  the  abdomen,  and 
tympanites,  and  later,  diarrhoea  of  a  most  offensive  character.  These 
are  the  initial  symptoms  of  peritonitis,  and  they  may  be  followed  in  a 
short  time  by  symptoms  of  septicaemia,  and,  later,  of  pyaemia.  It  is 
a  question  yet  to  be  settled,  whether  septicgemia  is  not  at  the  bottom 
of  this  unfavorable  change.  A  certain  amount  of  bloody  and  serous 
oozing  always  takes  place  when  adhesions  are  broken  up  during  the 
operation.  Frequently  this  is  promptly  absorbed  without  producing 
the  slightest  disturbance ;  but,  under  some  unknown  circumstances,  it 
is  absorbed  very  slowly,  and  in  a  few  hoars  may  undergo  septic 
changes,  and  poison  the  whole  mass  of  the  blood.  To  secure  the  safe 
removal  of  this  "oozed"  fluid,  and  to  keep  down  the  patient's  tempe- 
rature, is  one  of  the  problems  of  this  branch  of  surgery.  The  reduc- 
tion of  temperature  does  not  insure  the  removal  of  the  blood  poison, 
but  it  renders  the  condition  of  the  patient  less  critical.  The  higher 
the  temperature  above  the  normal,  the  greater  will  be  the  tissue  waste, 
and  the  more  seriously  will  the  action  of  the  kidneys  and  other  excre- 
tory organs  be  impaired,  even  to  the  extent  of  total  arrest,  and,  of 
course,  death.  An  increased  action  of  the  kidneys,  skin,  and  other 
excretory  organs  is  essential  when  blood-poisoning  exists.  A  reduc- 
tion of  the  temperature  to  the  normal  (that  is  when  it  has  not  been 
brought  about  by  exhaustion)  favors  functional  activity,  and  secures 
a  more  rapid  elimination  of  septic  material,  and  affords  time  for  the 
institution  of  remedial  measures. 

Among  the  so-called  antipyretics,  quinine  is  the  only  one  which  is 
worthy  of  confidence.  To  produce  a  marked  effect  it  must  be  given 
in  large  doses;  but  the  stomach,  in  its  ii-ritable  state,  is  not  apt  to 
tolerate  any  drug,  and  the  absorbing  power  of  the  rectal  mucous 
membrane  is  too  slight  to  enable  us  to  expect  great  results  from  the 
introduction  of  remedies  in  that  direction.  The  external  application 
of  cold,  dry  or  wet,  has,  from  time  to  time,  been  highly  extolled  for 
the  reduction  of  temperature,  but  hitherto  the  difficulties  in  the  way 
of  its  application  have  greatly  limited  its  use. 

Dr.  Richardson  seems  to  have  been  the  first  ovariatomist  who  em- 
ployed cold,  by  means  of  an  ice-bag  about  the  neck,  with  a  view  of 
directly  lowering  the  temperature  of  the  blood  going  to  the  brain  and 
nerve  centres.  But  his  method  was  crude  and  inconvenient,  and  it 
proved  impossible  to  keep  the  ice-bag  in  position. 

xVt  length,  Mr.  J.  K.  Thornton,  of  London,  suggested  an  improved 


REDUCTION    OF    TEMPERATURE.  841 

ice-cap  in  the  form  of  a  coil  of  small  India-rubber  tubing,  through 
which  a  constant  current  of  ice  Avater  was  made  to  flow.  This  ar- 
rangement has  met  with  Mr.  Wells's  entire  approval,  and  he  states^ 
that  "it  is  very  seldom  that  within  an  hour  the  effect  upon  the  ))utient 
cannot  be  distinctly  proved  by  the  thermometer,  and  I  believe  in 
many  cases  it  has  been  of  very  signal  service." 

Yet  it  is  evident  that,  for  speedily  reducing  the  temperature  of  the 
whole  body,  the  application  of  cold  to  the  head  alone  is  limiting  it  to 
too  small  an  area,  although  ray  own  experience  does  not  extend 
beyond  the  use  of  the  cold  cap  and  sponging  of  the  face  and  extremi- 
ties. To  Dr.  T.  G.  Thomas  we  are  indebted  for  information  as  to  the 
most  effective  means^  for  applying  cold  to  the  body,  and  from  it  we 
are  promised  an  advance  in  ovariotomy  second  only  in  importance  to 
that  made  by  the  introduction  of  "Listerizing." 

Dr.  Thomas  has  used  at  the  Woman's  Hospital  the  "fever-cot"  of 
the  late  Dr.  G.  W.  Kibbee,  who  died  in  the  discharge  of  his  duty,  as 
a  volunteer,  during  the  recent  (1878)  epidemic  of  yellow  fever  in 
New  Orleans,  where  he  was  experimenting  with  his  cot  in  the  treat- 
ment of  that  disease. 

The  "fever-cot"  is  essentially  the  same  as  the  low,  narrow  and 
folding  cot  so  commonly  used  as  a  temporary  bed.  A  strong  elastic 
cotton  nettino;  is  substituted  for  the  stretched  canvas,  and  beneath 
this,  for  the  whole  length,  and  from  one  side  to  the  other,  hangs  a 
piece  of  rubber  cloth.  The  water  readily  runs  through  this  netting 
to  the  rubber  cloth  below,  which,  hanging  loose,  forms  a  gutter,  and 
conveys  the  water  to  a  bucket,  or  other  receptacle,  at  the  foot  of  the 
bed. 

The  following  is  Dr.  Thomas's  description  of  his  method. 

"  Upon  this  cot  a  folded  blanket  is  laid  so  as  to  protect  the  patient's 
body  from  cutting  by  the  cords  of  the  netting,  and  at  one  end  is  placed 
a  pillow  covered  with  India-rubber  cloth,  and  a  folded  sheet  is  laid 
across  the  middle  of  the  cot  about  two- thirds  of  its  extent.  Upon  this 
the  patient  is  now  laid,  her  clothing  is  lifted  up  to  the  arm-pits,  and 
the  body  enveloped  by  the  folded  sheet,  which  extends  from  the  ax- 
illae to  a  little  below  the  trochanters.  The  legs  are  covered  by  flannel 
drawers,  and  the  feet  by  warm  woolen  stockings,  and  against  the  soles 
of  the  latter  bottles  of  Avarm  water  are  placed.     Two  blankets  are 

'  Fifth  lecture,  Brit.  Med.  .Journ.,  July  13,  1878. 

2  The  most  effectual  method  for  controlling  the  high  temperature  occurring 
during  ovariotomy.  New  York  Med.  Journ.,  August,  1878. 


842  ABDOMINAL    OVAEIOTOMY. 

then  placed  over  her,  and  the  application  of  water  is  made.  Turning 
the  blankets  down  below  the  pelvis,  the  physician  now  takes  a  large 
pitcher  of  water  at  from  75°  to  80°  and  pours  it  gently  over  the 
sheet.  This  it  saturates,  and  then,  percolating  the  netAvork,  it  is 
caught  by  the  India-rubber  apron  beneath,  and,  running  down  the 
gutter  formed  by  this,  is  received  in  a  tub  placed  at  its  extremity  for 
that  purpose.  Water  at  higher  or  lower  degrees  of  heat  than  this 
may  be  used.  As  a  rule,  it  is  better  to  begin  with  a  high  tempera- 
ture, 85°  or  even  90°,  and  gradually  diminish  it. 

"  The  patient  now  lies  in  a  thoroughly  soaked  sheet  with  warm  bottles 
to  her  feet,  and  is  covered  up  carefully  with  dry  blankets.  Neither 
the  portion  of  the  thorax  above  the  shoulders  nor  the  inferior  extremi- 
ties are  wet  at  all.  The  water  is  applied  only  to  the  trunk.  The 
first  effect  of  the  affusion  is  often  to  elevate  the  temperature,  a  fact 
noticed  by  Currie  himself;  but  the  next  affusion,  practised  at  the  end 
of  an  hour,  pretty  surely  brings  it  down.  It  is  better  to  pour  water 
at  a  moderate  degree  of  coldness  over  the  surface  for  ten  or  fifteen 
minutes  than  to  pour  a  colder  fluid  for  a  shorter  time.  The  water 
slowly  poured  robs  the  body  of  heat  more  surely  than  when  used  in 
the  other  way.  The  water  collected  in  the  tub  at  the  foot  of  the  bed, 
having  passed  over  the  body,  is  usually  8°  or  10°  warmer  than  it  was 
when  poured  from  the  pitcher.  On  one  occasion  Dr.  Van  Vorst,  my 
assistant,  tells  me  that  it  had  gained  12°. 

"At  the  end  of  every  hour  the  result  of  the  affusion  is  tested  by  the 
thermometer  ;  and,  if  the  temperature  has  not  fallen,  another  affusion 
is  practised,  and  this  is  kept  up  until  the  temperature  comes  down  to 
100°  or  even  less. 

"It  must  be  appreciated  that  the  patient  lies  constantly  in  a  cold 
wet  sheet ;  but  this  never  becomes  a  fomentation,  for  the  reason  that 
as  soon  as  it  abstracts  from  the  body  sufficient  heat  to  do  so,  it  is 
again  wet  Avith  cold  water  and  goes  on  still  Avith  its  Avork  of  heat  ab- 
straction. I  have  kept  patients  upon  this  cot  enveloped  in  the  Avet 
sheet  for  tAvo  and  three  Aveeks,  Avithout  discomfort  to  them,  and  with 
the  most  marked  control  over  the  degree  of  animal  heat.  Ordinarily 
after  the  temperature  has  come  doAA^n  to  99°  or  100°,  four  or  fiA-e 
hours  Avill  pass  before  affusion  again  becomes  necessary." 

"  Recognizing  in  this  a  method  by  Avhich  cold  could  be  applied  to 
the  surface  for  any  length  of  time  Avithout  fatigue  or  exhaustion  to  the 
patient,  and  Avithout  the  danger  of  excessive  chilling,  since  any  great 
depression  of  temperature  can  be  obviated  by  the  aft'usion  of  Avarm 
water,  I  determined  at  once  to  adopt  it  after  ovariotomy." 


DKATNAGE.  843 

Dr.  Thomas  has  given  the  history  of  eight  cases  treated  by  this 
method,  and  the  fact  is  clearly  estal)lished  by  these  records  that  the 
rise  in  temperature  can  be  kept  under  control. 

The  reduction  of  temperature  is  all  very  well,  so  far  as  it  goes,  but 
the  patient  will  die  in  spite  of  it,  unless  the  decomposing  bloody  serum 
is  removed  from  the  peritoneal  cavity. 

If  a  drainage  tube  has  been  left,  communicating  through  the  ab- 
dominal incision  with  Douglas's  cul-de-sac,  it  can  be  ascertained  if  an 
accumulation  of  fluid  has  taken  place  there.  This  tube  should  be 
kept  well  corked  until  symptoms  of  blood  poisoning  arise,  when  it  is 
to  be  opened  frequently  to  admit  of  the  escape  of  any  fluid  that  may 
be  in  the  cavity ;  and  a  hard  rubber  syringe  with  a  long  narrow  nozzle 
tipped  with  an  inch  or  so  of  small  tubing  perforated  with  one  or  more 
small  holes,  should  be  passed  to  the  bottom  of  the  drainage  tube  to 
remove  what  has  not  run  out.  Afterwards  a  weak  solution  of  car- 
bolic acid  in  warm  water  should  be  injected  with  the  greatest  care, 
and  continued  until  the  fluid  begins  to  return  through  the  tube,  when 
it  is  to  be  drawn  out  with  the  syringe,  and  the  injection  repeated  until 
the  water  returns  clear.  This  must  be  done  as  often  as  may  be  in- 
dicated, for  when  the  quantity  is  great  it  may  be  necessary,  in  some 
cases,  to  wash  out  the  cavity  every  hour  or  two,  Avhile  in  others,  twice 
in  the  twenty-four  hours  will  be  sufiicient. 

A  cup  sponge,  which  has  been  saturated  with  a  solution  of  carbolic 
acid,  can  be  kept  over  the  mouth  of  the  drainage  tube  after  the  first 
dressing.  If  any  portion  of  the  bandage  is  found  wet  and  soiled  by 
the  discharge,  or  any  odor  can  be  detected,  the  dressing  must  be 
changed,  and  always  under  the  spray. 

The  final  removal  of  this  drainage  tube  will  depend  on  circumstances, 
but  it  should  be  withdrawn  in  five  or  six  days  if  possible.  It  soon 
becomes  surrounded  by  lymph,  which  forms  a  canal  to  the  bottom  of 
Douglas's  cul-de-sac,  and  the  pressure  of  the  glass  tube  is  more  or  less 
irritating,  and  excites  a  discharo;e  which  Avould  not  otherwise  take 
place.  After  the  fourth  day,  if  it  cannot  be  dispensed  with,  a  shorter 
glass  tube,  or  a  piece  of  rubber  tubing,  should  be  used,  the  size  to  be 
reduced  from  day  to  day  both  as  to  length  and  diameter.  To  prevent 
the  tubing  from  slipping  into  the  abdominal  cavity,  a  loop  of  thread 
should  be  fastened  to  its  outer  end.  When  no  drainage  tube  has  been 
used,  and  symptoms  of  blood  poisoning  come  on,  the  lowest  angle  of 
the  wound  must  be  opened,  under  the  spray,  with  a  probe,  and  the 
position  of  the  patient  changed  to  aid  the  escape  of  any  fluid  in  the 
cavity.     A  vaginal  examination  must  also  be  made,  and  if  any  fluid 


844  ABDOMINAL    OVARIOTOMY. 

can  be  detected  in  Douglas's  pouch,  it  must  be  at  once  evacuated  by 
puncture. 

The  tympanites  which  always  exists  more  or  less,  in  even  the  most 
favorable  cases,  can  be  only  palliated  if  excessive.  Ten  or  twenty 
drops  of  chloroform,  with  as  many  grains  of  powdered  camphor  dis- 
solved in  it,  and  administered  in  a  little  gum  water,  will  sometimes 
give  relief  when  the  stomach  is  sufficiently  quiet  to  tolerate  any 
remedy.  The  application  of  dry  heat  to  the  abdomen  is  always 
grateful,  and  frequently  the  only  relief  which  can  be  gained  is  through 
changing  the  patient's  position.  This  can  be  done  without  much  dis- 
turbance, by  lifting  one  side  of  the  mattress,  and  placing  a  pillow 
under  it ;  this  Avill  shift  the  position  of  the  patient  sufficiently  to  one 
side  to  give  temporary  relief. 

The  catheter  should  be  introduced  for  four  or  five  days,  after  which 
it  will  be  safe  to  move  the  patient  sufficiently  to  use  the  bed-pan.  It 
is  scarcely  ever  necessary  to  cause  the  bowels  to  act  before  the  end  of 
the  first  week,  and  then  it  is  better  to  employ  an  enema  of  warm  water, 
and  a  little  Castile  soap  for  the  purpose. 

I  feel  fully  satisfied,  from  my  own  observation,  that  much  harm  has 
been  done  by  the  indiscriminate  use  of  opium  after  ovariotomy. 
Under  some  circumstances  the  effect  of  opium  seems  to  increase  the 
action  of  the  kidneys,  but,  as  a  rule,  its  secondary  effect,  if  not  its 
primary  one,  is  to  diminish  the  secretion,  particularly  of  the  skin. 
Opium  is  unquestionably  a  valuable  remedy,  and  should  be  used  Avith- 
out  hesitation  when  needed.  It  often  serves  to  economize  the  patient's 
strength  by  allaying  pain,  and  by  producing  sleep.  Its  use  is  also 
essential  to  hold  in  check  the  early  vomiting  of  peritonitis,  but  it  should 
never  be  used  as  a  prophylaxis  against  its  occurrence.  The  plan  so 
often  followed  of  giving  large  doses  of  opium  from  the  beginning,  and 
of  keeping  the  patient  fully  under  its  influence,  has  killed  a  great  num- 
ber by  arresting  the  secreting  or  eliminating  processes. 

As  long  as  the  patient  seems  to  be  doing  well,  the  bandage  ought 
not  to  be  disturbed  until  the  sutures  are  to  be  removed,  which,  if  they 
are  of  silk,  ought  to  be  in  four  or  five  days,  and  if  metallic,  at  the  end 
of  one  week.  When  the  course  of  the  convalesence  has  been  favorable, 
the  patient  is  generally  able  to  sit  wp  for  a  short  time  at  the  end  of 
the  second  week,  and  in  from  four  to  six  weeks  she  may  be  able  to 
return  home.  She  should  continue  to  use  an  abdominal  bandage  for 
several  months  after  the  o])cration.  This  will  give  support  to  the 
tissues  which  have  been  so  louii;  overstretched,  and  will  at  the  same 


ANTISEPTICS.  845 

time  guard  against  a  separation  along  the  line  of  incision,  and  the 
occurrence  of  a  hernia. 

\Ve  cannot  conclude  this  subject  in  a  more  appropriate  manner  than 
by  presenting  to  the  reader,  the  latest  views  of  Mr.  Wells  and  Mr. 
Keith  regarding  the  antiseptic  mode  of  treatment. 

Mr.  Wells  has  stated  in  one  of  his  lectures,  "  I  think  I  have  already 
noticed  a  considerable  difterence  in  the  progress  of  cases  after  opera- 
tion since  I  began  to  use  carbolic  acid  and  thymol.  There  has  dis- 
tinctly been  less  elevation  of  temperature  in  every  one  of  the  cases 
than  I  have  ever,  or  only  exceptionally,  seen  before.  I  may  say  that, 
in  antiseptic  ovariotomy,  fever  is  the  exception,  when  as  formerly  it 
was  the  rule." 

Mr.  Wells,  in  addition,  states  that  in  his  hospital  practice,  for  the 
past  two  years,  he  had  had  ninety  per  cent,  of  recoveries. 

Mr.  Keith's  success  in  this  operation  had  been  unequalled  previous 
to  employing  Lister's  method,  and  the  effect  of  its  adoption  and  the 
advantage  gained  cannot  be  better  expressed  than  in  his  own  words.' 
"  Without  antiseptics,  my  results  over  fourteen  years  gave  a  mortality 
of  almost  1  in  7.  Of  the  five  years  preceding  the  use  of  the  spray, 
nearly  1  "in  lOJ,  of  the  last  of  these  five  years  1  in  21,  To  what 
then  are  these  results  to  be  attributed  ?"  He  attributes  this  success 
first  to  the  use  of  the  drainage  tube,  which  has  been  described,  and 
states,  "  I  am  as  certain  as  I  am  of  my  existence,  that,  had  I  used 
them  earlier  and  oftener,  the  mortality  would  have  been  less  by  one- 
third."  He  next  rates  in  value  the  use  of  the  cautery  in  dividing 
the  pedicle  ;  then  the  compression  forceps  in  large  numbers  to  pre- 
vent loss  of  blood ;  and  finally  the  substitution  of  ether  for  chloro- 
form. "  All  these  things  have,  I  think,  helped  to  lessen  the  mortality, 
but  the  drainage  and  the  employment  of  the  cautery  in  the  division  of 
the  pedicle,  have  contributed  most." 

"What  then  have  we  gained  by  antiseptics  in  ovariotomy  ?  1.  It 
has  lessened  the  mortality.  Take  the  results  of  the  German  surgeons. 
After  the  first  trials  even,  the  mortality  fell  at  once  from  50  per  cent, 
to  20 :  thirty  lives  saved  by  the  spray  alone  out  of  every  hundred. 
When  I  add  that  my  last  forty- one  have  all  recovered,  enough  has 
been  said.  No  such  successful  series  was  ever  got  in  the  old  way." 
.  .  .  "  2.  This  increased  safety  will  encourage  medical" men  to  recom- 
mend earlier  operations,  which  certaiidy  few  of  them  now  do.     That 

1  Kesnlts  of  Ovariotomy  before  and  after  Antiseptics,  by  T.  Keith,  F.R.C.S., 
Edinburgh,  British  Medical  Journal,  Oct.  19,  1878. 


846  ABDOMINAL    OVARIOTOMY. 

very  large  tumors  and  bad  adhesions  increase  the  mortality  there  can 
be  doubt.  For  the  last  seven  years,  no  death  happened  to  me  in  non- 
adherent tumors,  and  the  deaths  that  occurred  during  that  period  were, 
with  a  single  exception,  in  cases  where  the  local  difficulties  prolonged 
the  operation  for  two  hours  or  more.  Certainly  early  operations, 
when  a  cyst  bursts,  and  fluid  is  thrown  out  in  a  large  quantity  into  the 
peritoneum,  cannot  be  too  strongly  urged.  3.  With  antiseptic  ovari- 
otomy, the  drainage  tube  will  not  be  nearly  so  often  required.  I  do 
not  think  that  it  can  be  altogether  dispensed  with.  iSTo  one  has 
practised  drainage  so  much  as  I  have,  yet  I  know  well  that  it  some- 
times cannot  be  used  without  risk."  "With  antiseptics  the  tube  can 
be  removed  much  earlier."  4.  "  Convalescence  is  rendered  easier. 
5.  Antiseptics  are  a  great  comfort  and  relief  to  the  operator.  Speak- 
ing for  myself,  the  difference  is  enormous ;  ovariotomy  is  not  the 
operation  it  was  fifteen  or  sixteen  years  ago,  or  even  two  years  ago." 
"  This  long  despised  operation  is  now  the  safest  of  all  the  great  surgi- 
cal operations,  at  least  judging  from  the  results,  twelve  deaths  of  the 
last  one  hundred  and  fifty-six,  three  of  the  last  seventy-five,  and  no 
deaths  of  the  last  forty-one  operations." 

The  introduction  of  the  antiseptic  method  justifies  us  now  in  under- 
taking the  removal  of  ovarian  tumors  at  a  much  earlier  stage  of  their 
growth.     In  some  cases  at  least  one  vear  mav  thus  be  gained. 


IKDEX. 


ABDOMINAL  ovariotomy,  797,  830 
tumors,  778 
Abscess,  69 

of  the  ovary,  748 

pelvic,  272,'  283 
Absence  of  the  uterus,  205 

of  the  vagina,  80,  203,  230 
Abstract  of  cases  of  vesico-  and  recto- 
vaginal fistula,  658 
Accidental  causes  of  disease,  90 
Adhesions  complicating  ovariotomy,  806 

mode  of  breaking  up,  in  ovariotomy, 
833 
Age  at  first  menstruation,  153  et  seq. 
Alison  on  injecting  ovarian  cysts,  791 
Amenorrlio3a,  175 
Amputation  of  the  cervix  uteri,  488 

mode  of  covering  the  stump, 

488 
substitutes  for,  484 

of  the  uterus,  439,  561 
Amussat  on  enucleation  of  fibroids,  556 

on  opening  the  vagina,  231 

on  retention  of  menstrual  blood,  210 
Anesthetics,  danger  of,  in  cystitis,  730 
Aneurisms  in  fibrous  growths,  523 
Anodynes,  95 
Anteflexion,  346 
Anteversion,  308 
Antiseptic  dressings,  838 
Antiseptics,    effect   of,   upon   results    of 

ovariotomy,  845 
Apoplexy,  ovarian,  237 
Applications  to  the  cervix,  131,  137 
Applicator,  29 

Artificial  vesico-vaginal  fistula,  728 
Ascites  complicating  ovariotomy,  803 
Asi^irator  for  ovarian  cysts,  786 
Assistants  in  ovariotomy,  819 
Atlee  on  diagnosis  of  ovarian  tumors,  779 

on  section  of  fibroids,  557 
Atmospheric  pressure,  effects  of,  on  va- 
gina, 129 
Atresia  of  the  vagina,  203 
Atrophy  of  the  uterus,  86 
Aveling  on  nidation,  151 

on  uterine  mucous  membrane,  150 


BAKER  on  malposition  of  ureter,  648 
Barker  on  malignant  disease  of  the 


uterus,  498,  504 


Barnes  on  amputation  of  the  uterus,  441 

on  inverted  titerus,  417  et  s<'.rj. 

on  ovaritis,  752 

on  passage  of  liquids  through  the 
uterine  Trails,  204 
Barnesfather  on  menstrual  blood,  150 
Barrier  on  inverted  uterus,  415 
Bath,  hot-air,  96 

Russian,  96 

Turkish,  96 
Battey  on  vaginal  ovariotomy,  797 
Battey's  oj^eration,  754 
Bedford  on  hematocele,  236 
Bed-pan,  51 
Bedridden  patients,  105 
Bernutz  and  Voisin  on  hematocele,  236 
Bichat  on  hematocele,  237 
Bigelow  on  lithotrity,  743 
Bimanual  palpation,  63 
Bladder,  overdistension  of,  during  par- 
turition, a  cause  of  fistula,  663 

sphincter  of  female,  726 

stone  in  the,  724,  740 
Blisters  to  the  cervix,  142 
Block  tin  rings,  316 
Blunt  hook,  47 
Boettcher  on  the  formation  of  ovarian 

cysts,  766 
Bourdon  on  hematocele,  235 
Bozeman  on  artificial  vesico-vaginal  fis- 
tula, 732 

on  the  button  suture,  616 

on  kolpokleisis,  614 

on  urethrocele  and  catarrh  of  the 
bladder,  729 
Braun  on  hematocele,  235 
Breisky  on  laceration  of  the  cervix,  445 
Brickell  on  pelvic  effusions,  284 
Broad  ligament,  cysts  of  the,  770,  773 
Brown  on  division  of  the  cervix  for  hem- 
orrhage, 556 

on  the  use  of  the  cautery  in  ovari- 
otomy, 824 
Byrne  on  hematocele,  236 


nALCULI,  vesical,  740 
vJ    Campbell  on  the  origin  of  calculi,  741 
Campbell's  pneumatic  repositor,  130 
Cancer  complicating  ovariotomy,  811 

diagnosis  of  uterine,  498 

etiology  of  uterine,  492 


848 


IXDEX. 


Cancer — 

of  external  organs  of  generation,  511 
prognosis  of,  497 
of  the  rectum,  511 
of  tlie  titerus,  490  et  seq. 
tables  of,  496  et  seq. 
treatment  of,  500 
varieties  of,  490 
Canney  on  inyerted  uterus,  415 
Caxjuron  on  inverted  uterus,  437 
Carbolic  acid,  133 
solution,  819 
Carcinoma,  491,  523 
Carpenter  on  menstrual  blood,  184 
Catheter,  sigmoid,  624 

importance   of    using   in   labor,   to 
prevent  fistula,  666 
Cauliflower  excrescence,  491 
Causes  of  disease,  76 

accidental,  90 
Caustics  and  cautery,  effects  of,  on  cer- 
vix, 131 
Cauterv  for  dividing  the  pedicle,  824 
Cellulitis,  66,  255 

dangers  of  probes,  tents,  etc.,  in,  144 
etiology  of,  260 
pessary  in,  286 
symptoms  of,  268 
tables  on,  263  et  seq. 
treatment  of,  275 
Cervix  uteri,  amputation  of,  481 
bifid  laceration  of,  472 
cicatricial  ectropium  of,  445 
cicatricial  hypertrophy  of,  471 
dilatation  of,  351 
diseases  of,  606 
elongation  of,  482 
flexures  of,  326 
incision  of,  354 
laceration  of,  445 

multiple,  or  stellate  laceration  of, 
475 
Chadwick  on  drainage  of  cystic  fluid, 

806 
Chromic  acid,  134 
Chronic  inflammation,  81 
Churchill  on  uterine  fibroids,  546 

on  uterine  hemorrhage,  552 
Cicatricial  bands  in  the  vagina,  232 
hypertrophy  of  the  cervix,  471 
plug  in  a  lacerated  cervix,  449 
tissue,  92 
Circulation,  pelvic,  82 
Clamp  for  securing  the  pedicle,  823 
Clarke  on  sex  in  education,  21 
Cleanliness  in  gy.na;cology,  60 
Climate,  influence  of,  17 

relations  of,  to  development,  17 
Clitoris,  liypertrophy  of,  592 
Cofr<-<>,  103 

Cold  water,  effects  of,  119 
Color  of  uterine  and  ovarian  cysts,  777 
Complications  in  ovariotomy,  799 
Conception,  149 


Congestion,  81 

Congestive  hyper troijhy  of  the  uterus,  83 

Connective  tissue  of  the  pelvis,  diseases 

of,  255 
Contents  of  ovarian  cysts,  445,  765 
Contraction  of  os  uteri,  caused  by  caus- 
tics, 133 
Copper  sound,  27 
Cornstalk  tents,  40 
Corpus  luteum,  cvst  of,  760 
Corroding  ulcer,  86,  491,  509 
Curette  forcejjs,  612 
Curette,  Simon's,  500 
Sims's,  500 

Thomas's  dull  wire,  500 
Cutter  on  uterine  fibroids,  548 
Cystic  degeneration  of  follicles,  608 
Cystitis,  724 
Cystocele,  381 

Cysto-fibroma  of  the  ovary,  759 
Cystoma,  comj^ound,  of  the  ovary,  760 
dermoid,  761,  767 
glandulare,  762 
myxoid,  761 
myxomatosum,  764 
papillare,  762 
parvilociilare,  763 
proliferum,  762 
sarcomatosum,  763 
Cystosarcoma,  763 
Cystotomy,  728 
Cysts,  65 

of  the  broad  ligament,  770,  773 

of  the  corpus  luteum,  760 

follicular,  760 

of  the  labia,  597 

mode  of  emptying,  in  ovariotomv, 

833 
of  the  ovary,  758 
compound,  769 
nionocystic,  769 
multilocular,  769 
oligocystic,  769 
polycystic,  769 
proligerous,  769 
unilocular,  769 


DAVIS  on  vaginal  ovariotomy,  797 
Dawson's  clamp,  825 
Denidation,  Aveling's,  151 
Dei^ressor,  Sims's,  26 
Dermoid  cysts  of  the  ovary,  761 
Details,  importance  of,  117,  145 
Devalz  on  utero-ovarian  varicocele,  237 
Development,  causes  of  imperfect,  20 
defects  of,  78 

relation  of  climate,  education,  etc., 
to,  17 
Diagnosis,  chief  points  for,  60 

dirt'erential,  between  fibrous  growths 
of  the  uterus  and  ovarian  tumors, 
776 
Dialyzed  iron,  549 


INDEX. 


840 


Diet,  101 

in  iitovine  fibroids,  5-iS 

in  ovariotomy,  81(j 
Dilatation  of  tlie  cervix,  139,  S'A 
Dilated  ureter,  (144 
Dilating  the  urethra,  71,  718 
Dilator,  sponge,  32 

■water,  35 
Displacements  of  the  uterus,  288 
Dome  trocar,  831 
Double  tenaculum,  46 

uterus,  208 

vagina,  208 
Drainage  after  ovariotomy,  843 
Dress,  114 
Dropsy  of  the  Fallopian  tube,  760 

of  the  Graafian  follicle,  760 
Drysdale  on  ovarian  tumors,  780 
Duncan  on  hematocele,  235 
Dunlap  on  division  of  the  pedicle,  827 
Duration  of  labor  in  relation  to  vesico- 
vaginal fistula,  662  et  seq. 
Dysmenorrhoea,  181,  185 

membranous,  183 

treatment  of,  187,  193 


EASTERLY  -wind,  influence  of,  on  sur- 
gical operations,  816 

Ecraseur,  Emmet's,  567 
mode  of  adjusting,  568 

Ectropium,  cicatricial,  of  the  cervix,  445 

Education,  relation  of,  to  development, 
20 

Elchwald,  on  ovarian  cysts,  763,  778 

Elephantiasis  of  the  labia,  592 

Elevator,  Emmet's,  28 
Sims's,  28 

Elongation  of  cervix,  482 

Embryonic  formations  in  ovarian  cysts, 
765 

Emmet  (Bache),  fistula  tube,  733 

on  animal  diet  in  fibroids,  548 

Emmet's  trocar,  831 

Endometritis,  81 

Endoscope,  711 

Engleman    on    uterine    mucous    mem- 
brane, 150 

Enucleation  of  ovarian  tumors,  827 

Enucleator,  Emmet's,  569 

Epithelioma,  86,  491 

Ergot,  injurious  etfects  of,  803 

in  the  treatment  of  uterine  fibroids, 
547 

Ether,  danger  of,  in  cystitis  with  renal 
disease,  730 

Evacuation  of  menstrual  blood,  229 

Examinations,  mode  of  making,  60 

External  organs  of  generation,  diseases 
of,  592 

Extirpation  of  the  nterus,  439,  561 

Extra-uterine     pregnancy,     differential 
diagnosis  of,  770 

Eyelet  for  fistula,  733 


FACIES  ovariana,  772 
Farre  on  uterine  mucous  membrane, 
150 
Feeder,  Sims's,  45 
Fibro-cysts  of  the  nterus,  514 
treatment  of,  560 
dilferential  diagnosis,  776 
color  of,  777 
Fibroid   and  fibrous    tumors,  dinen-nc<' 

between,  85 
Fibroids  of  the  uterus,  514 
etiology  of,  524 

influence  on  nKmstrnation,  530 
interstitial,  518 
multiple,  521 
situation  of,  526 
submucous,  518 
sub-peritoneal,  518 
Fibroma  of  the  ovary,  759 

of  the  uterus,  516 
Fibromyoma,  514 

Fibrous  growths  of  the  uterus,  514 
animal  diet  in,  548 
tables  of,  525  et  seq. 
treatment : 

by   bromide  of  potassium, 

546 
by  chloride  of  calcium,  546 
by  electrolysis,  546 
by  ergot,  546 
by  gallic  acid,  552 
surgical,  564 
Fibrous  polypus,  564 
Fibrous  tumors  of  the  ovary,  removal  of, 
828 
of    the     uterus,    complicating 
ovariotomy,  813 
Fissure  of  the  neck  of  the  bladder,  717 
Fistula,  vesico-  and  recto-vaginal,  614 
causes  of,  659 
etiology  of,  659 

instrumental  delivery  in  rela- 
tion to,  673 
prolonged  labor  in  relation  to, 

662  et  seq. 
tables  of,  660  et  seq. 
Fitch's  dome  trocar,  831 
Fletcher  on  opening  the  vagina,  210 
Flexures  of  the  cervix,  293,  326,  347 
of  the  nterus,  293 
causes  of,  346 
etiology  of,  326 
frequencv  of,  327 
lateral,  350 

menstruation  with,  328 
treatment  of,  351 
tables  on,  327  et  seq. 
Follicles,  Graafian,  drojisy  of,  760 
inflammation, of,  746 
Nabothian,  cystic   degeneration  of, 
608 
inflammation  of,  608 
Forceps,  twisting,  45 
curette,  612 


850 


IXDEX, 


For^e  on  aneurisms  in  fibrous  growths, 

523 
Form  for  recording  cases,  58 
Foster's  vaginal  syringe,  53 
Foulis  on  ovarian  fluid,  783 
Freshening  surfaces,  mode  of,  47 
Freund  on  fibrous  tumors  and  cancer,  828 
Fungosities  of  the  uterine  canal,  610 


GAXGLIO^'IC  nerves,  influence  of,  76, 
88 
Gilmore  on  vaginal  ovariotomv,  797 
Glass  plug,  232,  621 
Glycerine,  134 
Goodell  on  spaying,  590,  756 

on  vaginal  ovariotomy,  797 
Gosset  on  vesico-vaginal  fistula,  614 
Graafian  follicles,  dropsy  of,  760 

inflammation  of,  746 
Granular    ovarian    cell,    or    corpuscle, 

780 
Granulations  of  the  uterine  canal,  610 
Gravity,  efi'ect  of,  in  oj)euing  the  vagina, 
129 


HALL  on  procidentia,  376 
Harrison  on  hematocele,  236 

on  retro-uterine  hematocele,  248 
Hayward  on  vesico-vaginal  fistula,  614 
Heat,  effects  of,  119 
Hebrews,  fruitfulness  of,  149 
Hegar  on  spaying,  590 
Hematocele,  66,  234 

pelvic,  234 

peri-uterine,  236 

retro-uterine,  236,  243 
Hemorrhage,  67 

agents  to  control,  551 

division  of  cervix  to  arrest,  556 

due  to  fibroids,  551 

hot  water  to  arrest,  123 
Hernia,  iimbilical,  mode  of  treating  in 

ovariotomy,  835 
Hicks  on  pregnancy  in  ovariotomy,  811 
Hilderbrandt  on  uterine  fibroids,  547 
Hodge's  pessary,  317 
Hollow  polypus,  411 
Hot-air  bath,  96 
Hot  water,  effects  of,  118,  123 

to  arrest  hemorrhage,  123 

vaginal  injections,  51,  120 
Hours  for  meals,  116 
Howard  on  uterine  fibroids,  572 
Huguier  on  amputating  the  cervix,  487 
Hydrosalpinx,  770 
Hygiene,  114 
Hymen,  imperforate,  211 
Hyperplasia  of  the  uterine  parenchyma, 

514 
Hypertrophy  of  the  clitoris,  592 

of  labia  and  nymplue,  594 

congestive,  83 


Hypertrophy — 

cicatricial,  of  cervix,  471 
Hysteria,  174,  199 


IMPACTION  of  foetal  head,  a  cause  of 
i     fistula,  669,  671 
Imperforate  hymen,  211 
Impregnation,  149 
Incision  of  cervix,  356 
Incontinence  of  urine,  719 

to  relieve,  635,  636 
Inflammation,  chronic,  81 

complicating  ovariotomy,  799 
of  the  uterus,  see  Congestive  Hyper- 
trophy. 
Injections  into  the  undilated  uterus,  141 
Instrumental  delivery  in  relation  to  fis- 
tula, 668 
Instruments,  case  of,  30 

required  in  ovariotomy,  817 
Intra-uterine  stem,  486 
Inversion  of  the  uterus,  408 

treatment  of:  Barnes's  :nethod, 
418 
Courty's  method,  417 
Emmet's  method,  419 
Noeggerath's  method,  417 
Smith's  method,  417 
Simpson's  method,  417 
Thomas's  method,  416 
Valentin's  method,  416 
Viardel's  method,  436 
Watt's  method,  418 
White's  method,  416 
Iodine,  135 

to  produce  uterine  contractions,  21 
Iron,  dialyzed,  549 

preparations  of,  101 


JACKSON,     on     exploration     of     the 
urethra,  711 
Jones  on  uterine  mucous  membrane,  150 


TZEITH  on  antiseptics  in  ovariotomy, 

IV  845 

on  the  cautery  in  ovariotomy,  825 
on   malignant    disease   of    ovarian 
cyst,  785 

Kidneys,   disease  of   the,    complicating 
ovariotomy,  812 

Kiwisch  on  abscess  of  the  ovary,  748 

on  fibrous  growths  of  the  uterus,  517 
on  inflammation  of  the  ovaries,  746 

Klebs,  on  fibrous  growths  of  the  uterus, 
514,  523 

Knee-elbow  position,  129 

Knife,  ball-and-socket,  43 

Koeborle,  on  ovarian  fluid,  778 

Kolpo-cystotomy,  733 

Kolpokieisis,  614 

Kussmaul,  on  absence  of  the  uterus,  205 


INDEX. 


851 


LABIA,  cysts  of  the,  507 
fatty  tumors  of  the,  r)f)4 
Lahiaand  uvinphre,  hypeitiophy  of,  594 

oozing  tumor  of,  595 
Labor,  jn-otracted,  iu  relation  to  fistula, 

{}lj2  et  se(j. 
Laceration  of  the  cervix,  445,  454 
bifid,  472 
diagnosis  of,  458 
eflects  of  on  menstruation,  454 
internal,  462 
multiple,  475 
stellate,  475 
tables  on,  448  et  seq.- 
treatment  of,  4t!4 
unilateral,  462 
of  the  perineum,  384 

ojieratiou  for,  387 
of  the  sphincter  ani,  397 

mode  of  suturing  in,  400 
operation  for,  402 
of  the  urethra,  71 8 
Lee  on  errors  in  diagnosis  of  tumors,  776 

on  hematocele,  236 
Leucorrlicea,  91,  92 
Levert,  on  vesico-vaginal  fistula,  614 
Lister's  dressing,  819 
Litholopaxy,  743 
Lithotrity,  743 


MADGE  on  hematocele,  235 
Malignant  disease  of  the  uterus,  490 
Malposition  of  the  ureter,  648 
McClintock  on  inverted  uterus,  431 

on  uterine  fibroids,  546 
hemori'hage,  552 
McCoy  on  inverted  uterus,  414 
Meadows  on  hematocele,  235 
Meals,  hours  for,  116 
Mechanical  treatment  of  versions,  308 
Meigs  on  inverted  uterus,  413 
Membranous  dysmenorrhcea,  183 
Menorrhagia,  178 
Menstrual  age,  average,  155 

blood,  evacuation  of,  229 
retention  of,  203 

flow,  abnormal  changes  iu,  174 
duration  of,  163 
Menstruation,  147 

age  at  first,  154  et  seq. 

changes  in,  174 

irregular,  177 

painful,  174 

profuse,  178 

regularity  of,  154 

scanty, 175 

tables  on,  152  et  seq. 

vicarious,  174,  197 

with  fibrous  growths,  530 

with  flexures  of  the  uterus,  330  et  seq. 

with  lacerations  of  the  cervix,  454 

with  versions  of  the  uterus,  298  et 
seq. 


Metamorphosis  of  ovarian  cysts,  764 
Metritis,  see  Congestive  llypertrojiliy. 
Mettauer  on  cancer  of  the  uterus,  505 

on  laceration  of  the  perineum,  387 

on  vesico-vaginal  fistula,  615 
Metzler  on  vesico-vaginal  fistula,  614 
Miller  on  inverted  uterus,  439 
Miner  on  enucleation  of  ovarian  tumors, 

827 
Mobility  of  the  uterus,  65 
Mode  of  making  examination,  60 

of  recording  cases,  58 
Monocysts  of  the  ovary,  769 
Moral  management,  110 
Mucous  follicles,  cystic  disease  of  the, 

93 
Mucous  polypus,  608 
Multilocular  cysts  of  the  ovary,  769 
Muud6  on  deaths  from  tapping  ovarian 
cysts,  787 

on  dull  wire  curette,  611 
Myo-adeno-cystoma  of  the  ovary,  759 
jNIyo-fibroma  of  the  ovary,  759 
Myoma  telangiectasis,  seu  caveruosum, 

'517 
Myomata,  516,  523 
Myxoid  cystoma  of  ovary,  761 


NABOTHIAN  follicles,  disease  of,  608 
Isausea,  hot  water  to  relieve,  839 
iVeedle  forceps,  45 
holder,  44 

Skene's,  for  the  perineum,  836 
Needles,  43 

Nelaton  on  division  of  the  cervix  for  he- 
morrhage, 556 
on  hematocele,  234 
Nerves,    sympathetic,    influence  of,  76, 

88 
Nervous  disorders,  88 
Neuralgia   from   disease  of  the  cervix, 

607 
Neuromatoid   growths    of  the   urethra, 

713,  714 
New  growths,  87 
Nidation,  151 
Nitrate  of  silver,  effects  of,  on  the  cervix, 

130 
Noeggerath  on  drainage  of  ovarian  cysts, 
796 
on  inverted  uterus,  415 
on  secretions  from  a  strictured  ure- 
thra, 92 
on  vagiual  puncture  of  ovarian  cysts, 
790 
Normal  ovariotomy,  755 
Normal  position  of  the  uterus,  128 
Nott,  on  injections  into  the  uterine  cav- 
ity, 142 
on  recto-urethral  fistula,  650 
Nussbaum  on  spaying  for  fibroids,  590 
Nutrition,  faulty,  81 


852 


INDEX, 


OCCLUSION  of  the  vagina,  221 
Oligocysts  of  the  ovary,  7t)9 
Oophoritis,  746 

Oozing  tumor  of  the  labia,  595 
Ovarian  apoplexy,  237 
Ovarian  cysts,  color  of,  777 
contents  of,  763 
embryonic  formations  in,  765 
enucleations  of,  827 
metamorphosis  of,  764 
treatment  of,  788 
Ovarian  fluid,  nature  of,  778 
granular  cell,  780 
trocars,  831 
Ovaries,    disease  of  both,   complicating 
ovariotomy,  813 
nerves  of  the,  147 
removal  of  the,  for  uterine  hemor- 
rhage, 590 
Ovariocentesis  vaginalis,  796 
Ovariotomy,  830 
abdominal,  796 
antiseptics  in,  845 
comj)lications  in,  799 
normal,  755 

preparatory  treatment  for,  814 
proper  time  for  performing,  814 
rectal,  797 
vaginal,  796 
Ovaritis,  746 
Ovary,  abscess  of  the,  748 

cysts  of  the,  758,  760,  769 
dermoid,  761 
myxoid,  761 
cysto-fibroma  of,  759 
cystoma,  compound,  of  the,  760 
diseases  of,  746 
enlargement  of  the,  751 
fibroma  of  the,  759 
follicular  cysts  of  the,  760 
irritable,  752 
myofibroma  of  the,  759 
sarcoma  of  the,  759 
solid  tumors  of  the,  758 
Ovulation,  147 


PAIN  of  menstruation,  157  et  seq. 
Fallen    on   artificial  vesico-vaginal 
fistula,  733 
Palpation,  bi-normal,  63 
Papillary  growths  in  ovarian  cysts,  781 
Papilloma,  491 

Paquelin's  therrno-cautere,  501 
Parametritis,  255 
I'arker  on  cystotojny,  728 
Parturition  .in  relation    to  fistula,   653, 

669 
Pean  on  extirpation  of  tlie  uterus,  561 
Pcaslee  on  cancer  of  tlie  uterus,  501 

on    development  of  ovarian   cysts, 

769 
on  ovarian  tumors,  759,  769 
on  renaoval  of  fibroids,  561 


Peaslee — 

on  rupture  of  ovarian  cysts,  803 
Pedicle,  division  of  the,  827 

mode  of  securing  the,  820,  834 
Pedunculated  fibroids,  564 
Pelvic  abscess,  272,  283 

cellular   tissue,    diseases    of    the, 

255 
circulation,  82 
hematocele,  234 

diagnosis  of,  252 
frequency  of,  239 
history  of,  234 
symptoms  of,  240 
treatment  of,  254 
Pelvis,  section  of  the,  289 
Perimetritis,  256 
Perineum,  laceration  of  the,  384 
Peritonitis,  256 

complicating  ovariotomy,  803 
Peri-uterine  hematocele,  236 
Personal  influence,  108 
Pessaries,  315 

Pessary,  modification  of  Hodge's,  317 
rubber  disk,  323 
sponge,  324 

for  procidentia,  373,  375 
Pflijger's  tubules,  765 
Phthisis  complicating  ovariotomy,  812 
Plaj^fair  on  pregnancy,  with  ovarian  tu- 
mors, 811 
Pneumatic  repositor,  130 
Polyoysts  of  the  ovary,  769 
Polypus,  fibrous,  564 
hollow,  411 
mucous,  608 
Position,  knee-elbow,  128,  130 
proper,  of  the  uterus,  125 
Pregnancy     complicating     ovariotomy, 
810 
diflTerential  diagnosis  of,  66 
extra-uterine,  69,  770 
tubal,  770 

with  cancer  of  the  uterus,  496 
Preparatory  treatment   for  ovariotomy, 
814 
for  vesico-vaginal  fistula,  617 
Princii^les  of  treatment,  94 
Probe,  dangers  of  the,  74 

Emmet's  silver,  27 
Procidentia  uteri,  291,  366 
causes  of,  366 
etiology  of,  368 
operation  for,  377 
pessary  for,  373,  375 
table  on,  370  et  seq. 
treatment  of,  371 
Prolapse  of  tlie  urethra,  715 

of  tlie  uterus,  see  Procidentia. 
Proligei-ous  cysts  of  the  ovary,  769 
Pruritus,  603 
Puberty,  153 
Purgatives,  99 
Pyo-nephrosis,  721 


INDEX, 


853 


Q 


UACKENBUSH 
415 


on    invcrtcfl   utorus, 


RECAMIER'S  cuiottc,  610 
Reeamier  on  lieinatocel*^,  234 
Recording  cases,  foinrfor,  58 
Rectal  examination,  70 
Rectal  ovariotomy,  797 
Recto-uretliral  fistula,  (ioO 
Recto-vaginal  fistula,  014,  648 
Rectum,  cancer  of  the,  511 

importance  of  examination  bv  the, 

773 
stricture  of  the,  049 
Reflex  action,  agents  for  exciting,  119 
Rei^ositor,  pneumatic,  130 
Rest,  importance  of,  after  applications  to 

the  uterus,  144 
Retention  c^'sts  of  the  ovary,  700 
of  menstrual  blood,  203 
of  urine,  how  effected  in  the  female 
bladder,  720 
Retractor,  Emmet's,  24 
Retroflexion,  349 

Retro-uterine  hematocele,  236,  243 
Retroversion  of  tlie  uterus,  64,  292 
mode  of  correcting,  309 
caused  by  fibroids,  550 
Richmond  on  opening  the  vagina,  231 
Rigby  on  uterine  fibroids,  546 
Rokitansky  on  uterine  fibroids,  514 

on  formation  of  ovarian  cysts,  700 
Roser  on  laceration  of  the  cervix,  440 
Routh  on  absence  of  the  vagina,  229 

on  epithelial  cancer  of  the  uterus,  505 
Rupture  of  cysts  complicating  ovarioto- 
my, 803 
Ruysch  on  hematocele,  235 


SALISBURY  on  uterine  fibroids,  548 
Sarcoma,  86,  491,  505,  523 
Sarcoma  of  the  ovary,  759 
Savage  on  the  supports  of  the  uterus,  288 

on  uterine  fibroids,  540 
Scanzoni  on  ovaritis,  746 
Schroeder  on  amputation  of  the  uterus,440 

on  dropsy  of  the  Graafian  vesicles,  760 

on  hematocele,  230 

on  oophoritis,  740 
Scirrhus  of  the  ovary,  759 
Scissors,  Emmet's,  41,  42 
Section  of  the  pelvis,  289,  290 
Shield,  Sims's,  27 
Shocks  on  rectal  ovariotomy,  797 
Silver  probe,  27 

sutures,  47 
Simon  on  closing  the  vagina,  636 

on  examinations  per  rectum,  70 

on  vesico-vaginal  fistula,  017,  023 
Simpson  on  hematocele,  235 

on  incision  of  the  cervix,  354 

on  inverted  uterus,  417 


Simpson — 

on  treatment  of  uterine  fibroids,  540 

on  use  of  caustic  for  fibroids,  557 
Simpson's  sound,  74 
Sims  on  amputation  of  the  cervix,  488 

on  cystocele,  381 

on  cystotomy,  728 

on  enucleation  of  fibroids,  550 

on  laceration  of  the  perineum,  387 

on  normal  ovariotomy,  750 

on  procidentia,  370 

on  retroversion  from  fibroids,  550 

on  silver  sutures,  48 

on  vaginismus,  000 

on  vesico-vaginal  fistula,  014 
Sims's  block-tin  rings,  310 

glass  plug,  232,  021 

self-retaining  catheter,  024 

speculum,  23 
Skaeon  inverted  uterus,  414 
Skene's  endoscope,  711 

needle,  830 
Slavjansky  on  inflammation  of  tlie  Graa- 
fian follicles,  740 

on  ovulation  and  menstruation,  149 
Smith  on  disintegration  of  uterine  lining 
membrane,  150 

on  inverted  uterus,  417 
Social  condition  in  relation  to  develoi> 

ment,  19 
Sound,  Sims's  copper,  27 
Spaying,  590,  750 
Sjjeculum,  Emmet's,  24 

Sims's,  23 

mode  of  using,  72 
Sphincter  ani,  laceration  of.  397 
table  on,  399 
ojjeration  for,  402 
Sphincter,  vesical,  726 
Spina  bifida,  a  unique  case  of,  775 
Sponge  dilator,  32 

holder,  27 

tents,  preparation  of,  31 
rules  for  using,  30 
Spray  apparatus,  818 
Statistical  history  of  vaginal  fistuke,  658 
Stillborn  children  in  relation  to  fistulse, 

673 
Stimulants,  95,  103 
Stone  in  the  bladder,  724,  740 

in  the  ureter,  724,  744 
Storer's  clamjj  sliield,  826 
Stricture  of  the  rectum,  649 
Sub-involution  of  the  uterus,  84,  443 
Supports  of  the  uterus,  288 
Sussdorf  on  hollow  polypus,  411 

on  tupelo  tents,  40 
Sutures,  mode  of  securing,  395 
Sympathetic  nerves,  influence  of,  70 
Synoptical  table  of  vesico-vaginal  fistula, 

678 
Syringe,  Foster's  vaginal,  53 

long  nozzle,  27 

vaginal,  53 


854 


IXDEX. 


rPABLE  I. 

II. 
III. 

IV. 

V. 

VI. 

VII. 

VIII. 

IX. 
X. 

XI. 

XII. 
XIII. 
XIV. 

XV. 

XVI. 

XVII. 

XVIII. 
XIX. 
XX. 

XXI. 

XXII. 

XXIII. 

XXIV. 

XXV. 

XXVI. 

XXVII. 

XXVIII. 

XXIX. 

XXX. 

XXXI. 

XXXII. 

XXXIII. 

XXXIV. 

XXXV. 

XXXVI. 

XXXVII. 

XXXVIII. 

XXXIX. 

XL. 

XLI. 

XLII. 

XLIII. 

XLIV. 

XLV. 

XLVI. 

XLVII. 


Regiilarity  of  menstmation, 

154 
Average  menstrual  age,  155 
Regularity  of  menstruation, 

156 
Regularity  of  menstruation, 

157 
Pain  of  menstruation,  157 
Ditto.  159 

Ditto.  160 

Regularity  of  menstruation, 

age  at  puberty,  162 
Pain  of  menstruation,  164 
Average  length,  of  flow,  167 
Lengtli    and    regularity    of 

flow,  168 
Changes  in  menstruation,  170 
Causes  of  retention,  211 
Causes  of  cellulitis,  263 
Complications  of  ceUulitis, 

264 
Menstruation  as  afl'ected  by 

cellulitis,  265 
Menstrual  flow  after  cellu- 
litis, 267 
Uterine  versions,  296 
Frequency  of  versions,  297 
Menstruation  with,  versions, 

298 
Menstruation  with,  versions, 

299 
Menstruation  withi  versions, 

303 
Menstruation  witht  versions, 

306 
Flexures  of  the  uterus,  327 
Ditto.  328 

Menstruation  with  flexures, 

332 
Menstruation  with  flexures, 

334 
Menstruation  with  flexures, 

338 
Menstruation  with  flexures, 

342 
Menstruation  with  flexures, 

344 
Procidentia,  370 
Laceration  of  sphincter,  399 
Lacei'ation  of  cervix,  448 
Ditto.  452 

Ditto.  453 

Ditto.  454 

Ditto.  456 

Cancer  of  the  uterus,  496 
■    Ditto.  497 

■  Fibrous  growths,  525 


Table— 

XLVIII. 

XLIX. 

L. 

LI. 

LII. 

LIII.  to  LXII 


534 
■  534 

536,  537 

538 

540 
Vesico-  and 


Ditto. 
Ditto. 
Ditto. 
Ditto. 
Ditto. 
Ditto. 
Ditto. 


525 
526 
527 
529 
530 
531 
532 


Fibrous  growths 
Ditto. 
Ditto. 
Ditto. 
Ditto, 
inclusive 
recto-vaginal  fistula,  660  et  seq. 
Tables  for  examinations,  60 
Tampon,  vaginal,  54 
Tapping  of  ovarian  cysts,  788 
Temperature,  reduction  of,  after  ovari 

otomy,  840 
Tenaculum,  double,  46 
Emmet's.  26 
Sims's,  26 
Tents,  cornstalk,  40,  138 
sponge,  31,  36,  139 
tupelo,  40 
Thermo-cautere,  501,  733 
Thomas   on   controlling   high   tempera 
ture,  841 
on  inverted  uterus,  417 
on  vaginal  ovariotomy,  796 
Thomas's  clamp,  825 

trocar,  791 
Thornton  on  ovarian  tumors,  779,  783 
Thymol  solution,  819 
Tilt  on  age  at  first  menstruation,  152 

on  hsematocele,  235 
Touch,  vaginal,  62 
Tourniquet,  uterine,  467 
Treatment,  general,  94 

local,  118 
Treatment  after  ovariotomy,  839 
of  ovarian  cysts,  788 
by  drainage,  795 
by  injection,  691 
by  removal,  798 
by  tapping,  788 
Trenholme  on  spaying,  590 
Trocar,  ovarian,  831 
Emmet's,  831 
Thomas's,  791 
Wells's,  831 
Tubal  pregnancy,  770 
Tumors,  68 

of  the  ovary,  cystic;  769 
Tupelo  tents,  40 
Turkish  bath,  96 
Twisting  forceps,  45 


ULCERATION  of  the  cervix,  81 
Umbilical  hernia,  how  treated,  in 
ovariotomy,  835  , 

Unilocular  ovarian  cysts,  769 
Ureter,  dilated,  644 
malposition  of,  048 
stone  in  the,  724,  744 
Urethra,  dilating  the,  71,  718 
diseases  of  the,  711 
exploring  the,  711 
injuries  to,  639 


INDEX, 


855 


Urethra — 

neuromatold  growths  of,  713 

vascuhar  growths  of,  714 
Urethritis,  71^5 
Urethrocele,  715 
Uretliro-vesical  fistuha,  626 
Ureto-vaginal  fistula,. 626,  642 
Urine,  incontinence  of,  71i) 

how  retained  in  female  bladder,  726 
Uterine  canal,  diseases  of  the,  606 
dilating  the,  139,  351 

fibro-cysts,  776 

lining  membrane,  150 

tourniquet,  467 
Utero-ovarian  varicocele,  237 
Uterus,  absence  of,  205 

amputation  of,  439,  561 

anatomical  supports  of,  288 

aneurism  in  fibrous  growths  of  the, 
523 

atrophy  of,  86 

cancer  of,  490 

color  of  cysts  of  the,  777 

congestive  hyj^ertrophy  of,  83 

displacements  of,  2S8 

double,  208 

enlargement  of,  66 

extirpation  of,  439,  561 

fibrous  and   cystic  growths  of,  514 
et  seq.,  776,  813 

flexures  of,  293 

inflammation  of,  see  Congestive  Hy- 
pertrophy. 

inversion  of,  408 

lining  membrane  of,  150 

malignant  disease  of,  490 

procidentia  of,  292,  366 

prolapse  of,  292,  366 

proper  position  of,  125 

versions  of,  292 


VAGINA,  absence  of,  80,  203,  230 
atresia  of,  203 
double,  208 
occlusion  of,  220 
opening  the,  231 
operation  for  closing,  614 
Vaginal  injections,  51,  120 
ovariotomy,  796 
syringe,  53 
tampon,  54 
touch,  62 


Vaginismus,  599 

Vaginitis,  602 

Valentin  on  inverted  uterus,  414 

Varicoci'le,  utfro-ovarian,  237 

Vascular  growths  of  the  urethra,  714 

Velpeau  on  enucleation  of  fibroids,  556 

Versions  of  the  uterus,  292 

ante-,  308 

etiology  of,  295 

frequency  of,  297 

lateral,  308 

menstruation  with,  298  et  seq. 

retro-,  64,  293 

tables  on,  296  et  seq. 

treatment  of,  307 
Vesical  sphincter,  726 
Vesico-vaginal  fistula,  614 

abstract  of  cases  of,  678 

artificial,  728 

causes  of,  659 

operation  for,  622 
Viardel  on  inverted  uterus,  435 
Vicarious  menstruation,  197 
Virchow  on  fibroids  of  the  uterus,  514 
source  of  the  blood  in  hematocele, 
239 
Vogel  on  laceration  of  the  cervix,  445 


WALDEYER  on  cysts  of  the  ovary,  761 
on  dropsy  of  the  Graafian  follicles, 
760 
Water  dilator,  35 

effects  of  hot,  118,  123 
Watts  on  inverted  uterus,  418 
Weir's  steam  spray,  818 
Wells  on  antiseptics  in  ovariotomy,  838, 
845 
on  malignant  tumors  of  the  ovary, 

782 
on  pregnancy  with  ovarian  tumors, 

811 
on  tapping  ovarian  cysts,  791 
on  uterine  fibroids,  546 
Wells's  clamp,  825 

trocar,  831 
West  on  inverted  uterus,  408,  440 
White  on  inverted  uterus,  415,  416 
Whitehead  on  menstrual  blood,  184 
Williams  on  uterine  lining  membrane, 

150 
Wing  on  vaginal  ovariotomy,  797 
Womb,  see  Uterus. 


(LATE    LEA   A;  BLANCHARD'H) 

OF 

MEDICAL  AND  SUKGICAL  PUBLICATIONS. 


In  asking  the  attention  of  the  profession  to  the  works  advertised  in  the  following 
paii^es,  the  publisher  would  state  that  no  pains  are  spared  to  secure  a  continuance  of 
the  confidence  earned  for  the  publications  of  the  house  by  their  careful  selection  and 
accuracy  and  finish  of  execution. 

'J"he  printed  prices  are  those  at  which  books  can  generally  be  supplied  by  booksellers 
throughout  the  United  States,  who  can  readily  procure  for  their  customers  any  works 
not  kept  in  stock.  Where  access  to  bookstores  is  not  convenient,  books  will  be  sent 
by  mail  post-paid  on  receipt  of  the  price,  and  as  the  limit  of  mailable  weight  has  been 
removed,  no  diificulty  will  be  experienced  in  obtaining  through  the  post-office  any 
work  in  this  catalogue.  No  risks,  however,  are  assumed  either  on  ihe  money  or 
the  books,  and  no  publications  but  ray  own  are  supplied,  so  that  gentlemen  will  in 
most  cases  find  it  more  convenient  to  deal  with  the  nearest  bookseller. 

An  Illustrated  Catalogue,  of  64  octavo  pages,  handsomely  printed,  will  be  for- 
warded by  mail,  post-paid,  on  receipt  of  ten  cents.  HENRY  C.  LEA. 

Nos.  706  and  708  Sansom  St.,  Philadelphia,  July,  1879. 


ADDITIONAL  INDUCEMENT  FOR  SUBSCRIBERS  TO 

THE  AMERICAN  JOURNAL  OF  THE  MEDICAL  SCIENCES. 


THKEE  MEDICAL  JOUENALS,  containing  over  2000  LARGE  PAGES, 
Free  of  Postage,  for  SIX  DOLLAES  Per  Annum. 

•  TERMS  FOR  1879. 

The  American  Journal  of  the  Medical  Sciences  and  1  Five  Dollars  per  annum, 
The  Medical  News  and  Library,  both  free  of  postage,  j  in  advance. 

'J'he  American  Journal  OF  THE  Medical  Sciences,  published  quar- ]  o-    ,.  ,. 

terly  (ll.oO  pages  per  annum),  with  |  ^    ' 

The  Medical  News  and  Library,  monthly  (.384  pp.  perannum),  and  [-  per  annum, 
The    Monthly    Abstract    of    Medical   Science  (592    pages    per  I   •        , 

annum).  V  1    .       1       I  i„  advance. 

SEPATiATE  SVIiSCRIVrrONS  TO 

The  American  Journal  of  the  Medical  Sciences,  when  not  paid  for  in  advance. 

Five  Dollars. 
'J'he  Medical  News  and  Library,  free  of  postage,  in  advance,  One  Dollar. 
The  Monthly  Abstract  of  Medical  Science,  free  of  postage,  in  advance.  Two 

Dollars  and  a  Half. 

%*  Advance-paying  subscribers  can  obtain  at  the  close  of  the  year  cloth  covers, 
gilt-lettered,  for  each  volume  of  the  Journal  (two  annually),  and  of  the  Abstract 
(one  annually),  free  by  mail,  by  remitting  ten  cents  for  each  cover. 

In  commencing  the  second  year  of  the  second  half  century  in  the  career  of  the 
"American  Journal  of  the  Medical  Sciences,"  the  publisher  has  much  pleasure  in 
assuring  its  wide  circle  of  readers,  that  at  no  former  period  has  it  had  the  prospect  of 
a  more  extended  sphere  of  usefulness.  Sustained  as  it  is  by  the  profession  of  the  whole 
United  States,  and  with  a  circulation  extending  to  every  country  in  which  the  English 
language  is  read,  the  efforts  of  the  editors  will  be  directed,  as  heretofore,  to  render  it  in 
every  way  worthy  of  its  reputation,  and  of  the  universal  favor  with  which  it  is  received. 
With  its  attendant  periodicals,  the  "Medical  News  and  Library"  and  the  "Monthly 
Abstract  OF  MedicalScience,"  it  combines  the  advantages  of  the  elaborate  preparation 
which  can  be  given  to  a  quarterly,  and  the  prompt  conveyance  of  intelligence  by  the 
monthly,  while,  the  whole  being  under  a  single  editorial  supervision,  the  subscriber  is 
secured  against  the  duplication  of  matter  inevitable  under  other  circumstances.  These 
efforts  the  publisher  seeks  to  second  by  offering  these  periodicals  at  a  price  unprece- 
dentedly  low — a  price  which  places  them  within  the  reach  of  every  practitioner,  and  gives 
the  equivalent  of  three  or  four  large  octavo  volumes  for  the  comparatively  trifling 

(For  The  "Obstetrical  Journal,"  see  p.  24.) 


2  Henry  C.  Lea's  Publications — (Am.  Journ.  Med.  Sciences). 

cost  of  Six  Dollars  per  aiinum. 

The  three  periodicals  thus  offered  are  universally  known  for  their  high  professional 
standing  in  their  several  spheres. 

I. 

THE  AMERICAN  JOURIsAL  OF  THE  MEDICAL  SCIENCES, 

Edited  BY  I.  MINIS  HAYS,  M.D., 
is  published  Quarterly,  on  the  first  of  January,  April.  July,  and  October.  Each  num- 
ber contains  nearly  three  hundred  large  octavo  pages,  appropriately  illustrated  wher- 
ever necessary.  It  has  now  been  issued  regularly  for  over  fifty  years,  during  the 
whole  of  which  time  it  has  been  under  the  control  of  the  present  senior  editor.  Through- 
out this  long  period,  it  has  maintained  its  position  in  the  highest  rank  of  medical  peri- 
odicals both  at  home  and  abroad,  and  has  received  the  cordial  support  of  the  entire 
profession  in  this  country.  Among  its  Collaborators  will  be  found  a  large  number  of 
the  most  distinguished  names  of  the  profession  in  every  section  of  the  United  States, 
rendering  its  original  department  a  truly  national  exponent  of  American  medicine.* 

Following  this  is  the  -Rkview  Department,"  containing  extended  and  impartial 
reviews  of  important  new  works,  together  with  numerous  elaborate  "Analytical  axb 
Bibliographical  Notices"  giving  a  complete  survey  of  medical  literature. 

This  is  followed  by  the  "Quarterly  Summary  of  Improtemexts  and  Discoveries 
i.\  the  Medical  Sciences,"  classified  and  arranged  under  different  heads,  presenting 
a  very  complete  digest  of  medical  progress  abroad  as  well  as  at  home. 

Thus,  during  the  year  1878.  the  "Journal"  furnished  to  its  subscribers  77  Original 
Communications,  133  Reviews  and  Bibliographical  Notices,  and  2.55  articles  in  the 
Quarterly  Summaries,  making  a  total  of  Four  Hundred  and  Sixty-five  articles 
illustrated  with  48  maps  and  wood  engravings,  emanating  from  the  best  professional 
minds  in  America  and  Europe. 

That  the  efforts  thus  made  to  maintain  the  high  reputation  of  the  "Journal"  are 
successful,  is  shown  by  the  position  accorded  to  it  in  both  America  and  Europe  as  a 
leading  organ  of  medical  progress : — 

This  is  nniveisally  acknotrleilged  as  the  leading  Oar  venerable  contemporary  has  our  best  wishes, 

American  Journal,  Hud  has  been  conducted  by  Dr.  and  we  can  onlyexpre-<3  the  hope  that  it  may  con- 

Hhts  alone  until  1S6S,  when  his  sou  was  associated  tinne  its  work  with  as  much  vigor  and  excellence  for 

wii"n.  him.     We  quite  agree  with  the  critic,  that  thi.s  the  next  fifty  years  as  it  has  exhibited  in  the  past, 

journal  is  second  to  none  in  the  language,  and  cheer-  — London  Lancet,  Jfov.  24,  1S77. 

fully  accord  to  it  the  first  place,  for  nowhere  shall  ^   ,   v     -.r    .-     ,        j  tjv,     •     i    t            i 

we  find  more  able  and  more  imoartial  criticism,  and  The  Philadelphia  Medical  and  Physical  Journal 

nowhere  such  a  repertory  of  able  original  articles,  'ssued  us  first  number  in  ls20,  and,  after  a  brilliant 

Indeed,  now  that  the  "B'riiishand  FJre^gn  Medicj-  career,   was   succeeded   in    1^27  by   the   American 

Cnirurgical  Review"  has  terminated  it.s  career,  the  Journal   of   the   Medical  .'sciences,  a    penodical   of 

American  Journal  stands  without  a  rival.— Xondow  world-wide  reputation  ;  the  ablest  and  one  of  the 

Mf.d.  Times  and  Gazette,  Nov.  24,  1S77.  oldest  periodicals  in  the  world-a  journal  which  has 

.        ^       „  an  unsullied  record. — Gross  s  History  of  American 

The  best  medical  journal  on  the  continent — Bos-  ^ed.  Literature   1S76. 

ton  Med  and  Surg.  Journal,  A])nin,lS79.  '    .    '            ,'■,.'          ,    ,                 i      .       v  • 

,,         ,          ,    ,      J        •!_      ,      ,      J-  This  is  the  medical  journal  of  our  country  to  whicn 

It  is  universally  acknowledged  to  be  the  leading  ^j^g  American  physician  abroad  will  point  with  the 

American  medical  journal,  and,  in  our  opinion,  is  greatest  satisfaction,  as  reflecting  the  slate  of  medical 

second  to  none  in  the  language.— Sosioji  Med.  and  culture  in  his  country.     For  a  great  many  years  it 

Hiirg.  Jour-iial,  Oct.  \hii.  ■)^.^.  been  the  medium  through  which  our  ablest  writ- 

The  present  number  of  the  American  Journal  is  an  ers  have  made  known  their  discoveries  and  observa- 

exceedingly  good  one.  and  gives  every  promise  of  tions — Aii/irtssof  L.  P.  Yandell,  M.D.,  before Inttr- 

maiutainiDg  the  well  earned  iepata;ion  .fihe  review,  national  Med.  Congress,  Sept.  1S76. 

And  that  it  was  specifically  included  in  the  award  of  a  medal  of  merit  to  the  Publisher 
in  the  Vienna  E.\hibition  in  1873. 

'I'he  subscription  price  of  the  "American  Journal  of  the  Medical  Sciences"  has 
never  been  raised  during  its  long  career.  It  is  still  Five  Dollars  per  annum  ;  and 
when  paid  for  in  advance,  the  subscriber  receives  in  addition  the  ".Medical  News  and 
Library,"  making  in  all  about  1500  large  octavo  pages  per  annum,  free  of  postage. 

THE  MEDICAL  KEWS  AND  LIBRARY 

is  a  monthly  periodical  of  'I'hirty-two  large  octavo  pages,  making  384  pages  per 
annum.  Its  '•Library  Department"  is  devoted  to  publishing  standard  works  on  the 
various  branches  of  medical  science,  paged  separately,  so  that  they  can  be  detached 
for  binding,  when  complete.  In  this  manner  subscribers  have  received,  without  ex- 
pense, such  works  as  "Watson's  Practice,"  "West  on  Children,"  "Malgaignk's 
Surgery,"  "Stokes  on  Fkver,"  Gosselin's  "Clinical  Lectures  on  Surgery,"  and 
many  other  volumes  of  the  highest  reputation  and  usefulness.  Witii  July,  1S78,  was 
commenced  the  publication  of  "Lectures  on  Diseases  of  the  Nervous  System,"  by 
J.  M.  Charcot,  Professor  in  the  Faculty  of  Medicine  of  Paris,  translated  from  the 
French  by  Geokgr   Sigerson,   M.D.,  Lecturer  on  Biology,  etc..  Catholic  Univ.  of 

*  CommunicaiioDii  are  invited  from  gentlemen  in  all  parte  of  the  conntry.  Elaborate  articles  inserted 
by  the  Editor  are  paid  for  by  the  Publisher. 


Henry  C.  Lea's  Publications — (Am.  Journ.  Med.  Sciences).         3 

Ireland  [see  p.  17),  which  will  be  continued  to  completion  during  1879.  New  sub- 
scribers, commencini!:  with  January,  1879,  can  procure  the  previous  portion  by  a 
remittance  of  50  cents,  if  promptly  made. 

The  "Nkws  DKrARTMKNT"  of  the  "Mkdical  News  and  Library"  presents  the 
current  information  of  tlie  month,  with  Clinical  Lectures  and  Hospital  Gleanings. 
A  new  and  attractive  feature  of  this  will  be  found  in  an  elaborate  series  of  Originai, 
American  Clinical  Lkctuiies,  specially  contributed  to  the  News  by  jreiitlemen  of 
the  hiiihest  reputation  in  the  profession  throughout  the  United  States.  During  lb7b 
there  have  appeared  Lectures  by 

S.  1).  Gross,  M.D..  Prof,  of  8urirery,  Jefferson  Med.  Coll.,  Philada. 

'V.  Gaii.laiid  Thomas.  M.I).,  Trof.  Obstetrics,  &c.,  Coll.  Phys.  and  Surg.,  N.  Y. 

William  Pepper,  M.D..  Prof.  Clin.  Medicine,  Univ.  of  Penna. 

Lewis  A.  Sayre,  M.D.,  Prof.  Orthopiedic  .Snrs^..Bellevue  llosp.  Med.  Coll..  NY. 
•  Roberts  Bartiiolow,  M.I).,  Prof.  Theory  and  Practice  of  Med.,  Med.  Coll.  of  Ohio. 

T.  G.  Richardson,  M.D.,  Prof.  Genl.  and  Clin.  Surg.,  Univ.  of  La.,  New  Orleans. 

S.  W.  Gross,  M.D.,  Surg,  to  Philada.  Hospitiil. 

F.  Peyre  Porcher,  M.D.,  Prof,  of  Mat.  .Med.  and  Clin.  Medicine,  Med.  Coll.  of  B.  C. 

William  Goodell,  M.D.,  Prof.  Clin.  Gvnajcolooy,  Univ.  of  Penna. 

N.  S.  Davis,  M.D..  Prof.  Prin   and  Pra'c.  of  Med.,  Chicago  Med.  Coll. 

W.  H.  Van  Buren,  M.D..  Prof.  Surgery,  Bellevue  Hosp.  Med.  Coll.,  N.  Y. 
To  be  followed  by  others  of  similar  value  from 

Austin  Flint,  M.D. ,  Prof.  Prin.  and  Prac.  of  Med:,  Bellevue  Hosp.  Med.  Coll..  N.Y. 

Fordyce  Barker.  M.D.,  Prof.  Clin.  Midwifery,  &c.,  Bellevue  Hosp.  Med.  Coll.,  N.Y. 

L.  A.  DuHRiNG,  M.D.,  Clin.  Prof,  of  Diseases  of  the  Skin,  Univ.  of  Penna. 

Theophilus  PARviN,]\l.D.,Prof.  Obstetrics,  &c..  Coll.  Phys.  and  Surg., Indianapolis. 

J.  P.  White,  M.D.,  Prof,  of  Obstetrics,  &c.,  Univ.  of  Buffalo. 

John  Ashhurst,  Jr.,  M.D.,  Prof,  of  Clin.  Surg.,  Univ.  of  Penna. 

D.  Warren  Brickell,  M.D.,  Prof.  Obstetrics,  &c..  Charity  Hosp.  Med.  Coll.,  N.  O. 

J.  Lewis  Smith,  M.D.,  Clin.  Lee.  on  Dis.  of  Chil.,  Bellevue  Hosp.  Med.  Coll.,  N.  Y. 

William  F.  Norris,  M.D.,  Clin.  Prof,  of  Diseases  of  the  Eye,  Univ.  of  Penna. 

P.  S.  Conner,  M.D.,  Prof,  of  Anat.  and  Clin.  Surgery,  Med.  Coll.  of  Ohio,  Cin. 

S.  Weir  Mitchell,  M.D.,  Phys.  to  the  Infirmary  for  Nervous  Diseases.  Philada. 

J.  M.  DaCosta,  M.D.,  Prof.  Prin.  and  Prac.  of  Med.,  Jeft'.  Med.  Coll.,  Philada. 

Thomas  G.  Morton,  M.D.,  Surgeon  to  Penna.  Hospital,  Philada. 

F.  J.  BuMSTEAD,  M.D.,  late  Prof,  of  Venereal  Dis.,  Coll.  Phys.  and  Surg.,  N.Y. 

J.  H.  Hutchinson,  M.D.,  Physician  to  Penna.  Hospital. 

Christopher  Johnson,  M.D.,  Prof,  of  Surgery,  Univ.  of  Md.,  Baltimore. 

William  Thomson,  M.D.,  Lecturer  on  Ophthalmology,  Jeff.  Med.  Coll.,  Philada. 

With  contributors  such  as  these,  repi'esenting  every  portion  of  the  United  States, 
the  publisher  feels  safe  in  promising  to  the  subscriber  a  series  of  practical  lectures 
unsurpassed  in  variety,  interest,  and  value. 

As  stated  above,  the  subscription  price  of  the  "  Medical  News  and  Library"  is 
One  Dollar  per  annum  in  advance;  and  it  is  furnished  without  charge  to  all  advance- 
paying  subscribers  to  the  "American  Journal  of  the  Medical  Sciences." 

III. 

THE  MO^'THLY  ABSTRACT  OF  MEDICAL  SCIENCE 

is  issued  on  the  first  of  every  month,  each  number  containing  forty-eight  large  octavo 
pages,  thus  furnishing  in  the  course  of  the  year  about  six  hundred  pages.  The  aim 
of  the  •'  Abstract"  is  to  present— without  duplicating  the  matter  in  the  "Journal" 
and  "News" — a  careful  condensation  of  all  that  is  new  and  important  in  the  medical 
journalism  of  the  world,  and  all  the  prominent  professional  periodicals  of  both  hemi- 
spheres are  at  the  disposal  of  the  Editors.  To  show  the  manner  in  which  this  plan 
has  been  carried  out  it  is  sufficient  to  state  that  during  the  year  1878  it  contained 

so  Articles  on  A.n.ritornff  n nil  I'lii/siohx/t/. 

.5'>  '*  •<    Mati'via,  Mctlicu  and  Thfrttpi-nticn. 

fiSO         "  "    JH'ffuiin: 

15  L  "  ''     Siirf/rri/. 

70  *•■  "     Slfitlifi/'frj/  nntl  Gynoecolof/j/. 

I'i  "  "    Mi'dicul  •j'uri.ipriiiicn.cc  and  Toxicology — 

making  in  all  .o.oB  articles  in  a  single  year. 

The  subscription  to  the  "  Monthly  Ab.stract,"  free  of  postage,  is  Two  Dollars 
AND  a  Half  a  year,  in  advance. 

As  stated  above,  however,  it  will  be  supplied  in  conjunction  with  the  "American 
Journal  of  the  Medical  Sciences"  and  the  "Medical  News  and  Library,"  makino- 
in  all  about  Twenty-onr  Hundred  pages  per  annum,  the  whole /ree  uf  postage,  for 
Six  Dollars  a  year,  in  advance. 

In  this  effort  to  bring  so  large  an  amount  of  practical  information  within  the  reach 
of  every  member  of  the  profession,  the  publisher  confidently  anticipates  the  friendly 


Henry  C.  Lea's  Publications — {Dictionaries). 


aid  of  all  who  are  interested  in  the  dissemination  of  sound  medical  literature.  He 
trusts,  especially,  that  the  subscribers  to  the  "American  Medical  Journal"  will  call 
the  attention  of  their  acquaintances  to  the  advantages  thus  offered,  and  that  he  will 
be  sustained  in  the  endeavor  to  permanently  establish  medical  periodical  literature 
on  a  footing:  of  cheapness  never  heretofore  attempted. 

PREMIUM  POE  OBTAINING  NEW  SUBSOEIBEES  TO  THE  "JOURNAL." 

Any  gentleman  who  will  remit  the  amount  for  two  subscriptions  for  1879,  one  of 
which  must  be  for  a  i\exu  auhscriher,  will  receive  as  a  premium,  free  by  mail,  a  copy  of 
"  Holtien's  Landmarks,  Medical  and  Surgical"  (for  advertisement  of  which  see  p. 
6),  or  of  Fothergill's  "  Antagonism  of  Medicines"  (see  p.  If!),  or  of  "  Browne  on 
the  Use  of  the  Ophthalmoscope"  (seep.  'i'.t).  or  of  "  Flint's  Essays  on  Conservative 
Medicine"  (see  p.  15),  or  of  "Sturges's  Clinical  Medicine"  (see  p.  14),  or  of  the 
new  edition  of  "Swayne's  Obstetric  Aphorisms"  (see  p.  21),  or  of  "Tanner's 
Clinical  Manual"  (see  p.  5),  or  of  "CiIambrrs's  Restorative  Medicine"  (see  p. 
18),  or  of  "West  on  Nervous  Disorders  of  Children"  (see  p.  20). 

*.^*  Gentlemen  desiring  to  avail  themselves  of  the  advantages  thus  offered  will  do 
well  to  forward  their  subscriptions  at  an  early  day,  in  order  to  insure  the  receipt  of 
complete  sets  for  the  year  1879. 

1^  The  safest  mode  of  remittance  is  by  bank  check  or  postal  money  order,  drawn 
to  the  order  of  the  undersigned.  Where  these  are  not  accessible,  remittances  for  the 
"Journal"  may  be  made  at  the  risk  of  the  publisher,  by  forwarding  in  registered 
letters.     Address, 

HENRY  C.  LEA,  Nos.  706  and  708  Sansom  St.,  Fhiladelphia,  Pa. 

J^UNGLISON  [ROBLEY),  M.D., 

"^  Late  Professor  of  Institutes  of  Medicine  in  Jefferson  Medical  College,  Philadelphia. 

MEDICAL  LEXICON;   A  Dictionary  of  Medical  Science:   Co«- 

tainin"  a  concise  explanation  of  the  various  Subjects  and  Terms  of  Anatomy,  Physiology, 
Pathology,  Hygiene,  Therapeutics.  Pharmacology,  Pharmacy,  Surgery,  Obstetrics,  Medicul 
Jurisprudence,  and  Dentistry.     Notices  of  Climate  and  of  Mineral  Waters;  Formulae  for 
Officinal,  Empirical,  and  Dietetic  Preparations ;  with  the  Accentuation  and  Etymology  of 
the  Terms,  and  the  French  and  other  Synonymes  ;  so  as  to  constitute  a  French  as  'well  as 
English  Medical  Lexicon.     A  New  Edition.     Thoroughly  Revised,  and  very  greatly  Mod- 
ified and  Augmented.     By  Richard  J.  I>unglison,  M.D.     In  one  very  large  and  hand, 
some  royaloctavo  volume  of  over  1100  pages.     Cloth,  $6  50;  leather,  raised  bands,  $7  50. 
iJust  Issued.) 
The  object  of  the  author  from  the  outset  has  not  been  to  make  the  work  a  mere  lexicon  or 
dictionary  of  terms,  but  to  afford,  undereach,  a  condensed  view  of  its  various  medical  relations, 
and  thus  to  render  the  work  an  epitome  of  the  existing  condition  of  medical  science.    Starting 
with  this  view,  the  immense  demand  which  has  existed  for  the  work  has  enabled  him,  in  repeated 
revisions,  to  augment  its  completeness  and  usefulness,  until  at  length  it  has  attained  the  position 
of  a  recognized  and  standard  authority  wherever  the  language  is  spoken. 

Special  pains  have  been  taken  in  the  preparation  of  the  present  edition  to  maintain  this  en 
viable  reputation.  During  the  ten  years  which  have  elapsed  since  the  last  revision,  the  additions 
to  the  nomenclature  of  the  medical  sciences  have  been  greater  than  perhaps  in  any  similar  period 
of  the  past,  and  up  to  the  time  of  his  death  the  authorlabored  assiduously  to  incorporate  every- 
thing requiring  the  attention  of  the  student  or  praeti'.ioner.  Since  then,  the  editor  has  been 
equally  industrious,  so  that  the  additions  to  the  vocabulary  are  more  numerous  than  in  any  pre- 
vious revision.  Especial  attention  has  been  bestowed  on  the  accentuation,  which  will  be  found 
marked  on  every  word.  The  typographical  arrangement  has  been  much  improved,  rendering 
reference  much  more  easy,  and  every  care  has  been  taken  with  the  mechanical  execution.  The 
work  has  been  printed  on  new  type,  srhall  but  exceedingly  clear,  with  an  enlarged  p.<»ge,  so  that 
the  additions  have  been  incorjiOTated  with  an  increase  of  but  little  over  a  hundred  pages,  and 
the  volume  now  contains  the  matter  of  at  least  four  ordinary  octavos. 

3  ;ience  so  extensive,  and  with  such  collaterals  as  medi- 
;ine,  it  is  as  much  a  nenessity  also  to  the  practisinR 
Dhysician.  To  meet  the  wants  of  students  and  most 
physicians,  the  dictionary   must  be  condensed  while 


A  book  well  known  to  our  readers,  and  of  wliir-h 
every  Auierioan  ought  to  be  proud.  When  the  learned 
author  of  the  work  passed  away,  probably  all  of  us 
feared  lest  the  book  should  not  maintain  its  place 
in  the  advancin;;  science  whose  terms  it  defines.  For- 
tunately, Dr.  Uichard  J.  nunt;lison,havinfc  assisted  his 
father  in  the  revision  of  several  editions  of  the  work, 
and  having  been,  therefore,  trained  in  theinetliods  and 
imbued  with  the  spirit  of  the  book,  has  been  able  to 
edit  it.  not  in  the  patcliwork  manner  so  dear  to  the 
lieart  of  book  editors,  so  repulsive  to  the  taste  of  intel- 
ligent book  readers,  but  to  edit  it  as  a  work  of  the  kind 
should  be  eilited— to  carry  it  on  .steadily,  without  jar 
or  interruption,  alotjg  the  grooves  of  tliought  it  has 
travelled  during  its  lifetime.  To  sliow  the  magnitude 
of  the  task  which  Dr.  Dunglison  has  assumed  and  car- 
ried through,  it  is  only  necessary  to  stale  that  more 
than  six  thousand  new  suVyects  have  been  added  in  the 
present  edition. — I'hila.  Med.  Times,  Jan.  3,  1874. 

About  the  first  book  purchased  by  the  medical  stu- 
dent is  the  Medical  Dictionary.  The  lexicon  explana- 
tory of  technical  terms  is  simply  &isine  qua  non.  In  a 


comprehensive,  and  practical  wliile  perspicacious.  Jt 
was  because  Dunglison's  met  these  indications  that  it 
became  at  once  the  dictionary  of  general  use  wherever 
medicine  was  studied  in  the  English  language.  In  no 
former  revision  have  the  alterations  and  a<Idition8  been 
)0  great.  More  than  six  thousand  new  subjects  and  terms 
have  been  added.  The  chiefterms  have  been  set  in  black 
letter,  while  the  derivatives  follow  in  small  caps;  an 
arrangement  which  greatly  facilitates  reference.  We 
may  safely  contirm  the  hope  ventured  by  the  editor 
"  that  the  work,  which  po.ssesses  for  him  a  filial  as  well 
IS  an  individual  interest,  will  be  found  worthy  a  con- 
tinuance of  the  position  so  long  accorded  to  it  as  a 
itandard  authority."— C«nct>inu<i  Clinic.  Jan.  10, 1874. 
It  has  the  rare  merit  that  it  certainly  has  no  rival 
In  the  English  language  for  accuracy  and  extent  of 
references. — London  Medical  Oazette . 


Henry  C.  Lea's  Publications — (Manuals). 


A  CRNTURY  OF  AMERICAN  MEniCINR.  ITTC-lHTC.  By  Doctors  E.  11. 
-*-*-  Clarke,  II.  J.  Bigelow,  S.  D.  Gross,  T.  G.  Tlioin;ia,  nnd  J.  S.  Billings.  In  one  very  hand- 
some 12uio.  volume  of  about  350  pnges  :  cloth,  $2  25.      (Just  Ready.) 

This  work  appeared  in  the  pages  of  the  American  Journal  of  the  Medical  Sciencesduring  the 
jear  1876.  A.«  a  detailed  account  of  the  development  of  medical  science  in  America,  by  gentle- 
men of  the  highest  authority  in  their  respective  departments,  the  profession  will  no  doubt  wel- 
come  it  in  a  form  adajited  for  iireservalion  and  reference. 


B 


R 


OBLYN  [RICHARD  D.),  M.D. 

A  DICTIONARY  OF  THE  TERMS  USED  IN  MEDICINE  AND 

THE  COLLATERAL  SCIENCES.  Revised,  with  numerous  additions,  by  Isaac  Hays. 
M.  D.,  Editor  of  the  "  American  Journal  of  the  Medical  Sciences."  In  one  large  royal 
12mo.  volume  of  over  500  double-columned  pages  ;  cloth,  $1  50  ;  leather,  $2  00 

It  is  the  best  book  of  defiuitions  we  have,  and  ought  always  to  be  upoa  the  student's  ia.i)\e.—SoxUhem 
Med.  and  Surg.  Journal. 

OD  WELL  (G.  F.),  F.R.A.S..  S^-c. 

A  DICTIONARY  OP  SCIENCE:  Comprising  Astronomy,  Chem- 
istry, Dynamics,  Electricity,  Heat,  Hydrodynnmic?,  Hydro.statics,  Light,  Miignetism, 
Mechanics  Meteorology,  Pneumatics,  Sound,  and  Statics.  Preceded  by  an  Ess;iy  on  the 
History  of  the  Physical  Sciences.  In  one  handsome  octavo  volume  of  694  pages,  and 
many  illustrations:  cloth,  $5. 

J^EILL  [JOHN),  M.D.,  and    JgMITH  [FRANCIS  G.),  M.D., 

Prof,  o/the  Institutes  of  Medicine  intheUniv  of  Penna 

AN    ANALYTICAL    COMPENDIUM    OF   THE    VARIOUS 

BRANCHES  OF  MEDICAL  SCIENCE;  for  the  Use  and  Examination  of  Students.  A 
new  edition,  revised  and  improved.  In  one  very  large  and  handsomely  printed  royal  12mo 
volume,  of  about  one  thousand  pages,  with  374  wood-cuts,  cloth,  $4  ;  strongly  bound  in 
leather,  with  raised  bands,  $4  75. 

TJARTSHORNE  [HENRY),  M.D., 

Professor  of  Hygiene  in  the  University  of  Pennsylvania. 

A    CONSPECTUS    OF    THE    MEDICAL    SCIENCES;    containing 

Handbooks  on  Anatomy,  Physiology,  Chemistry,  Materia  Medica,  Practical  Medicine", 
Surgery,  and  Obstetrics.  Second  Edition,  thoroughly  revised  and  improved.  In  one  large 
royal  12mo.  volume  of  more  than  1000  closely  printed  pages,  with  477  illustrations  on 
wood.  Cloth,  $4  25  ;  leather,  $5  00.  {Lately  Issued.) 
We  caa  say  with  the  strictest  truth  ihat  it  is  the  ]  deats,  but  to  many  others  whomay  desire  torefresh 
best  work  of  the  kind  with  which  w:  art  acquainted  !  their  memories  with  the  smallest  possible  expend  i- 
It  embodies  in  a  Condensed  form  aii  recent  coutiibii-  i  ture  of  time. — N.  Y.  Med.  Journal   Sept.  1S7-1. 

The  student  will  find  this  the  mostconvenient  and 
useful  book  of  the  kind  on  which  he  can  lay  his 
hand. — Pacific  Med.  and  Hurg.  Journ.,  Aug.  1S74. 
This  is  the  best  book  of  its  kind  that  we  have  ever 
examined.  It  is  an  honest,  accurate,  and  concite 
compend  of  medical  sciences,  as  fairly  as  possible 
representing  their  present  condition.  The  changes 
and  the  additions  have  been  so  judicious  and  tho- 
rough as  to  render  it, so  far  ai»  it  goes,  entirely  trust- 
worthy.    If  students  must  have  a  conspectus,  they 

will  be  wise  to  procure  that  of  Dr.  Harlshorne. 

Detroit  Rev.  of  Med.  and  Ptiarm.,  Aug.  1871. 


tions  to  practical  medicine,  ana  is  therefore  useful 
to  every  busy  practitioner  throughout  our  country, 
besides  being  admirably  adapted  to  the  use  of  stu- 
dents of  medicine.  The  book  is  faithfully  and  ably 
executed. —  Charleston  Med.  Journ.,  April,  1S73. 

The  work  is  intended  as  an  aid  to  the  medical 
student,  and  as  such  appears  to  admirably  fulfil  its 
object  by  itsexcellent  arrangement,  the  full  compi- 
lation of  facts,  the  perspicuity  and  terseness  of  lan- 
guage, and  the  clear  and  instructive  illustrations 
in  some  parts  of  the  work. — American  Journ.  of 
Pharmacy,  Philadelphia,  July,  1874. 
The  volume  will  be  found  useful,  not  only  to  stu- 


rUDLOW  [J.L.),  M.D. 
A   MANUAL   OF  EXAMINATIONS  upon  Anatomy,  Physiology, 

Surgery,  Practice  of  Medicine,  Obstetrics,  Materia  Medica,  Chemistry,  Pharmacy,  and 
Therapeutics.  To  which  is  added  a  Medical  Formulary.  Third  edition,  thoroughly  revised 
and  greatly  extended  and  enlarged.  With  370  illustrations.  In  one  handsome  royal 
12mo.  volume  of  816  large  pages,  cloth,  $3  25  ;  leather,  $3  75. 
The  arrangement  of  this  volume  in  the  form  of  question  and  answer  renders  it  especially  suit- 
able for  the  ofiBce  examination  of  students,  and  for  those  preparing  for  graduation. 

mANNER  [THOMAS  HAWKES),  M.D.,  Sfc. 

A  MANUAL  OF  CLINICAL  MEDICINE  AND  PHYSICAL  DIAG- 
NOSIS.   Third  American  from  the  Second  London  Edition.    Revised  and  Enlarged  bj 
Tilbury  Fox,  M.  D.,  Physician  to  the  Skin  Department  in  University  College  Hospital, 
&c.   In  one  neat  volume  small  ]2mo.,  of  about  375  pages,  cloth.  $1  50. 
.    *^*  On  page  4,  it  will  be  seen  that  this  work  is  offered  as  a  premium  for  procuring  new 
subscribers  to  the  "American  Journal  of  the  Medical  Sciences." 


Henry  C.  Lea's  Publications — (Anatomy). 


QRAY  {HENRY),  F.B.S., 

Lecturer  on  Anatomy  at  St.  George's  Hospital,  London. 

ANATOMY,  DESCRIPTIYE    AND  SURGICAL.     The  Drawings  by 

H.  V.  Carter,  M.D.,  and  Dr.  Westmacott.  The  Dissectionsjointly  by  the  Author  and 
Dr.  Carter.  With  an  Introduction  on  General  Anatomy  and  Development  by  T. 
Holmes,  M.A.,  Surgeon  to  St.  George's  Hospital.  A  new  American,  from  the  eighth 
enlargec  and  improved  London  edition.  To  which  is  added  "  Lakdiiarks,  Medical  and 
Surgical,"  by  Luther  Holden,  F.R  C.S.,  author  of  "  Human  Osteology,"  "A  Manual 
of  Dissections,"  etc.  In  one  magnificent  imperial  octavo  volume  of  983  pages,  with 
622  large  and  elaborate  engravings  on  wood.  Cloth,  $6  ;  leather,  raised  bands,  $7. 
{Just  Ready.) 

The  author  has  endeavored  in  this  work  to  cover  a  more  extendedrange  of  subjects  than  iscuc- 
tomary  in  the  ordinary  text-books,  by  giving  not  only  the  details  necessary  for  the  student,  but 
also  the  application  of  those  details  in  the  practice  of  medicine  and  surgery,  thusrendering  it  both 
a  guide  for  the  learner,  and  an  admirable  work  of  reference  for  the  active  practitioner.  The  en- 
gravings form  a  special  feature  in  the  work,  many  of  them  being  the  size  of  nature,  nearly  all 
original,  and  having  the  names  of  the  various  parts  printed  on  the  body  of  the  cut,  in  place  of 
figures  of  reference,  with  descriptions  at  the  foot.  They  thus  form  a  complete  and  splendid  series, 
which  will  greatly  assist  the  student  in  obtaining  a  clear  idea  of  Anatomy,  and  will  also  serve  to 
refresh  the  memory  of  those  who  may  find  in  the  exigencies  of  practice  the  necessity  of  recalling 
the  details  of  the  dissecting  room  ;  while  combining,  as  it  does,  a  complete  Atlas  of  Anatomy,  with 
a  thorough  treatise  on  systematic,  descriptive,  and  applied  Anatomy,  the  work  will  be  found  of 
essential  use  to  all  physicians  who  receive  students  in  their  offices,  relieving  both  preceptor  and 
pupil  of  much  labor  in  laying  the  groundwork  of  a  thorough  medical  education. 

Since  the  appearance  of  the  last  Americnn  Edition,  the  work  has  received  three  revisions  at  the 
hands  of  its  accomplished  editor,  Mr,  Holmes,  who  has  sedulously  introduced  whatever  has  seemed 
requisite  to  maintain  its  reputation  as  a  complete  and  authorifc>'iive  standard  text-book  and  work 
of  reference.  Still  further  to  increase  its  usefulness,  there  has  been  appended  to  it  the  recent 
work  by  the  distinguished  anatomist,  Mr.  Luther  Holden — "Landmarks,  Medical  and  Surgical" 
— which  gives  in  a  clear,  condensed,  and  systematic  way,  all  the  information  by  which  the  prac- 
titioner can  determine  from  the  external  surface  of  the  body  the  position  of  internal  parts.  Thus 
complete,  the  work,  it  is  believed,  will  furnish  all  the  assistance  that  can  be  rendered  by  type  and 
illustration  in  anatomical  study.  No  pains  have  been  spared  in  the  typographical  execution  of 
the  volume,  which  will  be  found  in  all  respects  superior  to  former  issues.  Notwithstanding  the 
increase  of  size,  amounting  to  over  100  pages  and  57  illustrations,  it  will  be  kept,  as  heretofore, 
at  a  price  rendering  it  one  of  the  cheapest  works  ever  offered  to  the  American  profession. 

to  consult  his  books  on  anatomy.  The  work  .is 
simply  indispensable,  especially  this  present  Amer- 
ican edition. —  Va.  Med.  Monthly,  Sept.  1S7P. 


The  recent  work  of  Mr.  Holden,  which  was  no- 
ticed by  us  on  p.  .53  of  this  volume,  has  been  added 
as  an  appendix,  so  that,  altogether,  this  is  the  most 
practical  and  complete  anatomical  treatise  available 
to  American  students  and  physicians.  The  former 
tiuds  in  it  the  necessary  guide  in  making  dissec- 
tions ;  a  very  comprehensive  chapter  ou  minute 
anatomy  ;  and  about  all  that  can  be  taught  him  on 
general  and  special  anatomy;  while  the  latter,  in 
its  treatment  of  each  region  from  a  surgieal  point  of 
view,  and  in  the  valuable  edition  of  Jlr  Holden, 
will  find  all  that  will  be  essential  to  him  in  his 
practice  — New  Remedies,  Aug.  1S7S. 

This  work  is  as  near  perfection  as  one  could  pos- 
sibly or  reasonably  expect  any  book  intended  as  a 
text-book  or  a  general  reference  book  on  anatomy 
to  be.  The  American  publisher  deserves  the  thanks 
of  the  profession  for  appending  the  recent  work  of 
Mr.  Holden, ''  Landmarks,  Medical  and  S(J.rgical," 
which  has  already  been  commended  as  a  separate 
book.  The  latter  work — treating  of  topographical 
anatomy — lias  become  an  e.ssential  to  the  library  of 
every  intelligent  practitioner.  We  know  of  no 
book  that  can  take  its  place,  written  as  it  is  by  a 
most  distingui.-hed  anatomist.  It  would  be  simply 
a  waste  of  words  to  say  anything  further  in  praise 
of  Gray's  Anatomy,  the  text-book  in  almost  every 
medical  college  in  this  country,  and  the  daily  refer- 
ence book  of  every  practitioner  who   has  occasion 


The  addition  of  the  recent  work  of  Mr.  Holden, 
as  an  appendix,  renders  this  the  most  practical  and 
complete  treatise  available  to  American  students, 
who  find  in  it  a  comprehensive  chapter  ou  minute 
anatomy,  about  all  that  can  be  taught  on  general 
and  special  anatomy,  while  its  treatment  of  each 
region,  from  a  surgical  point  of  viey,  in  the  valu- 
able section  by  Mr.  Holden, i«  all  that  will  be  essen- 
tial to  them  in  practice. —  Oliio  Medical  Recorder, 
Aug.  1S7S. 

It  is  difficult  to  speak  in  moderate  terms  of  this 
new  edition  of  "  Gray."  It  seems  to  be  as  nearly 
perfect  as  it  is  possible  to  make  a  book  devoted  to 
any  branch  of  medical  science.  The  labors  of  the 
eminent  men  who  have  successively  revised  the 
eight  editions  through  which  it  has  passed,  would 
seem  to  leave  nothing  for  future  editors  to  do.  Tlie 
addition  of  Holden's  "  Landmarks"  will  make  it  as 
indispensable  to  the  practitioner  of  medicine  and 
surgery  as  it  has  been  heretofore  to  the  student.  .\s 
regards  completeness,  case  of  reference,  utility, 
beauty,  and  cheapness,  it  has  no  rival.  No  slu- 
di'Ut  should  enter  a  medical  school  without  it  ;  no 
physician  can  afford  to  have  it  absent  from  his 
library. — St.  Louis  Clin.  Record,  Sept.  1S7S. 


ff 


H 


Also  for  sale  separate — 
VLDEN  {LUTHER),  F.E.C.S., 

Surgeon  to  St.  Barlliolomew's  and  the  Foundling  Ho,i]^itnIs. 

LANDMARKS,  MEDICAL  AND  SURGICAL.    From  the  2(1  London 

Ed.   In  one  handsome  volume,  royal  ]2mo.,  of  128  pages  :  cloth,  88  cents.    {Now  Ready.) 
EATH  {CHRISrOPHEK),  F.R.C.S., 

Teacher  of  Operative  Surgery  in  University  College,  London. 

PRACTICAL  ANATOMY:    A  Manual  of  Dissections.     From  the 

Second  revised  and  improved  London  edition.  Edited,  with  additions,  by  W.  W.  Kekn, 
M.  D.,  Lecturer  on  Pathological  Anatomy  in  the  Jefferson  Medical  College,  Philadelphia. 
In  one  handsome  royal  12mo. volume  of  678  pages,  with  247  illustrations.  Cloth,  $3  60  ; 
leather,  $4  00. 


Henry  C.  Lea's  Publications — (Anatomy). 


A  LLEN  (HAKRISON),  M.D. 

■^^  Profis^or  of  riiysioliigy  in  the  Univ.  nf  Pa. 

A  SYSTP:M  of  human  ANATOMY:  I^'CLUDING  ITS  jNfRDICAL 

and  Surgii-al  Relati(.ns.  For  the  Use  of  Piactitiuners  and  Students  of  Medicine.    Willi  iin 
Introductory  Chapter  on  Ilistolo;;y.  By  E.  0.  Siiakkspkake,  M  D.,  Oiihtlialniologist  to  the 
Phiia.  IIosp.    In  one  large  and  handsome  qunrto  volume,  with  several  hundred  orieinal 
illustrations  on  lithograjhic  plates,  and  numerous  wood-cuts  in  the  text.      {Preparhig.) 
In  this  elaliorate  work,  which  has  been  in  active  prepnration  for  several  years,  the  author  has 
sought  to  give,  not  only  the  details  of  descri[itive  anatomy  in  a  clear  iind  condensed  form,  but  also 
the  practical  applications  of  the  science  to  medicine  and  surgery.  The  work  thus  has  claims  upon 
the  attention  of  the  general  practitioner,  as  well  as  of  the  student,  enabling  hirn  not  only  to  re- 
fresh his  recollections  of  the  dissecting  room,  but  also  to  recognize  the  significance  of  all  varia- 
tions from  noruKil  conditions.      The  marked  utility  of  the  object  thus  sought  by  the  iiuthor  is 
self  evident,  and  his  long  experience  and  assiduous  devotion  to  its  thorough  development  area 
sufficient  guarantee  of  the  manner  in  which  his  aims  have  been  carried  out.   No  pains  li.ive  been 
spared  with  the  illustrations.   Those  of  normal  anatomy  are  from  original  dissecti  jns,  drawn  on 
stone  by  Mr.  Hermann  Faber,  with  the  name  of  every  part  clearly  engraved  upon  the  figure, 
after  the  manner  of  "llolden"  and  "Gray,"  and  in  every  typographical  detail   it  will  be  the 
efiort  of  the  publi.-her  to  render  the  volume  worthy  of  the  very  distinguished  position  which  is 
anticipated  for  it. 

PILIS  {GEORGE   VIiVER), 

-*-'  Emeritus  Proftssor  «f  Ariatumy  in  University  College,  London. 

DEMONSTRATIONS  OF  ANATOMY;  Being  a  Guide  to  the  Know- 

ledge  of  the  Human  Body  by  Dissection.  By  George  Viner  Ellis,  Emeritus  Professor 
of   Anatomy   in    University   College,    London.     From   the  Eighth  and  Kevised  London 
Edition.     In  one  very  handsome  octavo  volume  of  over  700  pages,  with  256  illustrations. 
Cloth,  S4. 2.5  ;   leather,  $5.26.      [Jvst  Ready.) 
This  work  has  long  been  known  in  England  as  the  leading  authority  on  practical  anatomy, 
and  the  favorite  guide  in  the  dissecting-room,  nsis  attested  by  the  numerous  editions  throuo-h 
which  it  has  passed.     In  the  last  revision,  which  has  just  appeared  in  London,  the  accomplished 
author  has  sought  to  bring  it  on  a  level  with  the  most  recent  advances  of  science  by  makinf  the 
necessary  changes  in  his  account  of  the  microscopic  structure  of  the  different  organs,  as  devel- 
oped by  the  latest  researches  in  textural  anatomy. 

Ellib'is  Demonstrations  is  the  favoiite  text-book  .  Us  leader.ship  over  the  English  manuals  upon  dis- 
of  the    English    student   of   anatomy.     In  passing  :  secting. — PhiLa.  Med.  Tintts,  May  24,  1S79. 
through  eight  editions  it  has  heen  »o  revised  and  ' 

Hdapted  to  the  needs  of  the  student  ihat  it  would  -*■•''  ^  dissector,  or  a  work  to  have  in  hand  and 
seem  thai  it  had  almost  reached  perfection  in  \hU  \  studied  while  one  is  engaged  in  dissecting,  we  re 
special  line.  The  descriptions  are  clear  and  the  !  g^'"d  '^^  ^^  "'^  '^'efy  best  wurk  extant,  which  is  cer- 
methods  of  pursuing  anatomical  invebtigations  are  \  tainly  saying  a  very  great  deal.  As  a  text-book  to 
given  with  suoli  detail  that   the  book  is  honestly  ,  ''e  studied  m  the  dissecting-room,  it  is  superior 


entitled  to  its  name. — St,  Louis  Clinical  Record, 
June,  1879. 

The  success  of  this  old  manual  seems  to  be  as  well 
deserved  in   the  present   as  in   the  past  volumei 


any  of  the  works  upon  a.'o.&iomy.— Cincinnati  Med 
News,  May  2t,  1879. 

We   most  unreservedly   recommend   it   to   every 
practitioner  of  medicine  who  can  p6ssiblyget  it. 


The  book  seems  destined  to  maintain  yet  for  years  1  Va.  Me'1.  Monthly,  June,  1879. 


'VUILSON  (ERASMUS),  F.R.S. 

A  SYSTEM  OF  HUMAN  ANATOMY,  General  and  Special.  Edited 

by  W.  H.  GoBEECiiT,  M.D  ,  Professor  of  General  and  Surgical  Anatomy  in  the  Medical  Col- 
lege of  Ohio.  Illustrated  with  three  hundred  and  ninety-seven  engravings  on  wood.  In 
one  large  and  ha.ndsome  octavo  volume,  of  over  600  large  pages  ;  cloth,  $4  ;  leather.  $5. 

JgAlITH  {HENRY E.),  M.D.,         and  JJORNER  (  WILLIAM  E.),  M.D., 

Prof,  of  Surgery  in  the  Univ.  of  Penna.,  &e.  LateProf.  of  Anatomy  in  the  Univ.  ofPenna.  ■ 

AN   ANATOMICAL   ATLAS,    Illustrative   of  the  Structure  of  the 

Human  Body.  In  one  volume,  large  imperial  octavo,  cloth,  with  about  six  hundred  and 
fifty  beautiful  figures.     $4  50. 

(^CHAFER  [ED  WARD  ALBERT),  M.D., 

^  Assistant  Profefsor  of  Physiology  in  University  College,  Lontfin 

A  COURSE  OF  PRACTICAL  HISTOLOGY:  Being  an  Introduction  to 

the  Use  of  the  Microscope.  In  one  handsome  royal  12mo.  volume  of  304  pages,  with 
numerous  illustrations:  cloth,  §2  00.     (Just  Issued.) 


HORNER'S  SPECIAL   ANATOMY  AND    HISTOL-     BELLAMYS    STUDENT'S    GUIDE    TO    SURGICAL 


OGY.  Eighth  edition,  extensively  revised  and 
modified.  In  2  vols.  Svo.,  of  over  1000  pages, 
■with  320  wood-cuts  :  cloth,  *fi  00. 
SHARPEY  AND  QUAIN'S  HUMAN  ANATOMY. 
Revised,  by  Joseph  Leidt,  M.D.,Prof  of  Anat. 
in  Uiiiv.  of  Penn.  In  two  octavo  vols,  of  about 
1300  pages,  with  511iUustrations     Cloth,  $6  00. 


ANaTUMY:  a  Text  book  for  Students  preparitg 
for  their  Pats  Exatr.ii  atiou.  With  engravines  on 
wood.  In  one  handsome  royal  12mo.  volume 
Cloth,  $2  2.j. 

CLELAND'S  DIRECTORY  FOR  THE  DLSSECTION 
OF  THE  HUMAN  BODY.  In  oce  small  volume, 
royal  12mo.  of  182  pages:  cloth,  f  I  2.0. 


8  Hexet  C.  Lea's  Publications — (Physiology). 


ffARPENTER  (  WILLIAM  B.),  M.  D.,  F.E.  S.,  F.G.S.,  F.L.S., 

RegUtrar  to  University  of  London,  etc. 

PRIXCIPLES  OFHTJMAX  PHYSIOLOGY;  Edited  hy  HexrtPower, 

M.B.  Lond.,  F.E.C.S  .  Examiner  in  iSatural  Sciences,  University  of  Oxford.  A  new 
American  from  the  Eighth  Eevised  and  Enlarged  English  Edition,  with  iS'otes  and  Addi- 
tions, bj-FRA>-cis  G.  Smith,  M.D.,  Professor^f  the  Institutes  cf  Medicine  in  the  Univer- 
sity of  Pennsylvania,  etc  In  one  very  large  and  handsome  octavo  volume,  of  1083  pages, 
with  twoplates  and  373  engravings  on  wood;  cloth,  $5  50  ;  leather,  $6  50.    {Just  Issued.) 

Thegreatwork,  the  crowning  labor  of  the  distinguished  author,  and  through  which  so  many 
generations  of  students  have  acquired  their  knowledge  of  Physiology, has  been  almost  meta- 
morphosed  in  the  effort  to  acapt  it  thoroughly  to  the  requirements  of  modern  science.  Since 
the  appearance  of  the  last  American  edition,  it  has  had  several  revisions  at  the  experienced 
hand  of  Mr.  Power,  who  has  modified  and  enlarged  it  so  as  to  introduce  all  that  is  important 
in  the  investigations  and  discoveries  of  England,  France,  and  Germany,  resulting  in  an  enlarge- 
ment of  about  one-fourth  in  the  text.  The  series  of  illustrations  has  undergone  alike  revision, 
a  large  proportion  of  the  former  ones  having  been  rejected,  and  the  total  number  increased 
to  nearly  four  hundred.  The  thorough  revision  which  the  work  has  so  recently  received  in 
Entrland.  hasrendered  unnecessary  any  elaborate  additions  in  this  country,  but  the  American 
Edftor,  Professor  Smith,  has  introduced  such  matters  as  his  long  experience  has  shown  him  to 
be  requisite  for  the  student.  Every  care  has  been  taken  with  the  typographical  execution  ,  and 
the  work  is  presente-d,  with  its  thousand  closely,  but  clearly  printed  pages,  as  emphatically  the 
text-book  for  the  student  and  practitioner  of  medicine — the  one  in  which,  as  heretofore,  especial 
care  is  directed  to  show  the  applications  of  physiology  in  the  various  practical  branches  of 
medical  science.  Notwithstanding  its  very  great  enlargement,  the  price  has  not  been  in- 
creased, rendering  this  one  of  the  cheapest  works  now  before  the  profession. 

We  have  been  agreeably  surprised  to  find  the  vol-  subject,  perfectly  certain  of  the  fulness  of  information 
nme  so  complete  in  regard  to  the  structure  and  func-  '  it  will  convey,  .ind  well  satisfied  of  the  accuracy  with 
tlons  of  tbe  nervoug  system  in  all  its  relations,  a  |  which  it  will  there  be  found  stated. — London  Med. 
Ettbiect  that.in  manyrespects,  is  oneof  the  mostdiffi- I  Times  and  Gazette,  Feb.  17,1877. 

cult  of  all,  in  the  whole  range  of  physiology,  upon  Thus  fully  are  treated  the  structure  and  functions  ol 
which  to  produce  a  fall  and  satisfactory  treatise  of  |  j^u  j^e  important  organs  of  the  bod}-,  while  there  are 
the  class  to  which  the  one  before  us  belongs.  The  i  chapters  on  sleep  and  somnambulism ;  chaptersoneth 
additions  by  the  American  editor  give  to  the  work  as  j  noloey.  a  full  section  on  generation,  and  abundant  re- 
it  is  a  considerable  value  beyond  that  of  the  last  I  ferences  to  the  curiosities  of  physiology,  as  the  evolu 
English  edition.  In  conclusion,  we  can  give  our  cor-  1  jj^^  ^f  light,  heat,  electricity,  etc.  In  short,  this  new 
dial  recommendation  to  the  work  as  it  now  appears,  i  edition  of  Carpenter  is,  as  we  have  said  at  the  start, 
The  editors  have,  with  their  additions  to  the  only  :  a  very  encyclopedia  of  modern  physiology.— r/te  Ctin- 
work  on  phvsioloKy  in  our  language  that,  in  the  full-  ^  jj  pgb  24, 1S77. 

est  sen.e  of'the  word,  is  the  production  of  a  philoso-  ;  '^rhemerits  of"  CarpentersPhysiology"  are  so  widelj 
pher  as  well  as  a  physiologist,  branght  it  up  as  fully  j  ^^„„„  ^^.^  appreciated  that  we  need  oSly  allude  briefly 
as  could  be  expected   if  not  desired   to  the  standard  ,  ^^^^.^  ^^^^  j^^^^^ ^^.^^.^^  ^,.j,  >  J 

of  our  knowledge  of  its  subject  at  the  present  day     ^^^j^^^^j^^  embodiment  of  the  results  of  recent  phv.^io 

ha 
of 


"Good  wine  tieed.«  no  bush"  says  the  proverb,  and 
an  old  and  faithful  servant  like  the  "  big"  Carpenter,  as 


evidence  of  the  amount  of  labor  that  has  been  bestowed 
upon  it  by  its  distinguished  editor,  Mr.  Henry  Power. 


carefully  brought  down  a.s  this  edition  has  been  by  Mr.  1  The  American  editor  has  made  the  latest  additions,  in 
Henry  Power."i<eeds  little  or  no  commendation  by  us.  j  order  fully  to  cover  the  time  that  has  elapsed  since  the 
Such  "enormous  advances  have  recently  been  made  in  ,  last  English  edition. — X  T.  Med.  Journal,  Jan.  1877. 
our  physiological  knowledge,  that  what  was  perfectly  j  ^  more  thorough  work  on  physiology  could  not  be 
new  a  year  or  two  ajro.  looks  now  as  if  it  had  been  a  ,  found.  In  this  all  the  facts  discovered  by  the  late  re- 
received  and  established  fact  for  years.  In  this  ency-  searches  are  noticed,  and  neither  student  nor  practi- 
clopsedic  way  it  is  unrivalled.  Here,  a.=  it  seems  to  tioner  should  be  without  this  e.xhaustive  treatise  on  an 
U8,i8thegreatvaineof  the  book:  one  is  safe  in  sending  ]  j^jportant  elementary  branch  of  medicine.— ^((an^a 
a  student  to  it  for  information  on  almost  any  given  \  j/^^.  and  Surg.  Journal.  Dec.  1876. 


JZIRKES  {WILLIAM  SENHOUSE),  M.D. 

A  MA>'UAL  OF  PHYSIOLOGY.    Edited  by  W.  Morraxt  Baker, 

M.D.,  F.R.C.S.  A  new  American  from  the  eighth  and  improved  London  edition.  With 
about  two  hundred  and  fifty  illustrations.  In  one  large  and  handsome  royal  12mo.  vol- 
ume.    Cloth,  $3  25;  leather,  $.5  75.      (Lately  Issued.) 

On  the  whole,  there  is.  very  little  in  the  book    physiology  which  we  have  in  our  language.— i\r.  r. 
which eitherthestndent  orpraclitionerwill  not  find     Med   Record,  April  LO,  1873. 

2L^;^:Sof^^:^s^aydry°ctan:M^T'c^e^e;'a;^d  we'  ^  In  us  enlarged  form  it  is,  in  ouropinion.  stilUhe 
LTno  hesitation  in  ex'pre, sin\  §ur  opinion  that  'T^^ZZ^'^^ll^^.^l-^l^'ll  "^8^3  '  '°  ''^'""•^*"- 
this  eighth  edition  Is  one  of  the  beet  handbooks  on    -^Ma.  Mea.  rime»,  Aug.  do,  lS7.i. 

HAtlTSHORNE'S  H.1XDBOOK  fiF  .^NATIMT  .^JfD  '      and  Additions,  by  J   Chesto."?  Morris   M.D.   With 
PUY-SIOLOGY.    Second  edition,  revised.    In  one        illostratioos  on  wood.     In  one  octavo  volume  of 
roTal    12mo.    vol.,    with    220   wood-cuts  ;    cloth,  ^      3.36  pages.     Clolh,  >2  2-5. 
$1>.5.  :  LKHMAXN'SPHY.SIOLOOICAL  CHEMISTRY  Com- 

LE'IMANK'S  manual  of  CHEMICAL  PHYSIOL-  1      plete  in  two  large  octavo  volumes  of  1200  pages, 
oVjY.     Translated  from  the  German,  with  Notes        with  200  illustratl  )ns  ;  cloth,  98. 


Henry  C.  Lea's  Publications — {Phyaiology). 


fk ALTON  {J.  C),  M.D., 

■L^  Pro/esfior  of  Phyni«h,gy  in  the  College  of  Phyaiciann  and  Surgeons,  Now  York.  Ac. 

A  TREATISE  ON  HUMAN  PHYSIOLOGY.    Designed  for  the  use 

of  Studentsand  Practitioners  of  Medicine.  Sixth  edition,  thoroughly  revised  and  enlarged, 
with  three  hundred  and  .-sixteen  illustrations  on  wood.  In  one  very  beautiful  octavo  vol- 
ume, of  over  800  pages.     Cloth,  $5  50;   leather,  $6  50.     i Just  Issued.) 


During  ihi!  past  few  ve»rs  several  new  works  on  phy- 
sidlogy,  and  new  eititions  of  old  wcjrk.",  liavea))peared, 
com|ieliiip  for  the  favor  of  the  medical  student,  but 
none  will  rival  thi.s  new  edition  of  Dalton.  As  now  en- 
larged, it  will  beloundalso  tobe,  in  ijeneral,  a  satisfac- 
tory work  of  refiTence  fi)r  the  practitioner. — Chicago 
iled.  Journ.  and  Examiner,  Jan.  1  876. 

Prof.  Dalton  has  discussed  conflictiuji  theories  and 
conclusions  refcarding  physiological  questions  with  a 
fairness,  a  fulness,  and  a  conciseness  which  lend  fresh- 
ness and  vigor  to  the  entire  book.  But  his  discussions 
have  been  sn  guarded  by  a  refusal  of  admission  to  those 
speculative  and  theoretical  explanations,  which  at  best 
exist  in  the  mind.sof  observers  themselves  as  only  pro- 
babilities, that  none  of  his  readers  need  be  led  into 
crave  errors  while  making  them  a  Study. — The  Medical 
'Record,  Feb.  19,  1870. 

The  revision  of  this  great  work  has,brought  it  forward 
with  the  physiological  advances  of  theday,  and  renders 
it,  as  it  has  ever  heen,  the  finest  work  for  students  ex- 
tant.— iVashville  Journ.  of  Med.  and  Surg.,  Jan.  1876. 

For  clearness  and  perspicuity,  Dalton's  Physiology 
commended  itself  to  the  student  years  ago.  and  was  a 
pleasant  relief  from  the  verbose  productions  which  it 
supplanted.  Physiolnjry  has.  however,  made  many  ad- 
vances since  then  — and  while  the  style  has  been  pre- 
served intact,  the  work  in  the  present  edition  has  been 
brought  up  fully  abreast  of  the  times.  The  new  chemical 
notation  and  nomenclature  have  also  been  introduced 
into  the  present  edition.  Notwithsianding  the  multi- 
plicity of  text-books  on  physiology,  this  will  lose  none 
of  its  old  time  popularity.  The  mechanical  execution 
of  the  work  is  all  that  could  be  desired. — Peninsular 
Journal  of  Medicine,  Dec.  1875. 


This  popular  texi-book  on  physiology  comes  to  us  in 
its  sixth  edition  with  the  addition  of  about  fifty  percent, 
of  new  matter,  chielly  in  the  departments  of  patho- 
logical chemistry  and  the  nervous  system,  where  the 
principal  advances  have  been  realized.  With  so  tho- 
rough revision  and  additions,  that  kceptlie  work  well 
up  to  the  times,  its  continued  pipularity  may  be  confi- 
dently predicted,  notwithstanding  the  competition  it 
may  encounter  .  The  publisher's  work  is  admirably 
done. — SI.  L'ui.s  Med.  and  Surg.  Journ  ,  Dec.  1875. 

We  heartily  welcome  this,  the  sixth  edition  of  this 
admirable  text  book,  than  which  there  are  none  of  equal 
brevity  more  valuable.  It  iscordially  recommended  Vjy 
the  Professor  of  Physiology  in  theUniversity  of  Louisi- 
ana, as  by  all  competentteachers  in  theUnited  States, 
and  wherever  the  linglish  language  is  read,  this  book 
has  been  appreoia  ed.  The  present  edition,  with  its  316 
admirably  executed  illustrations,  has  been  carefully 
revised  and  very  lUuch  enlarged,  although  its  bulkdoes 
not  seem  perceptibly  increased. — New  Orleans  Medical 
and  Surgical  Journal,  March,  1876. 

The  present  edition  is  very  much  superior  to  every 
other,  not  only  in  that  it  brings  the  subject  up  to  the 
times,  but  that  '\*  dois  so  more  fully  and  satisfactorily 
than  any  previous  edition.  Takeit  altogether  it  remains 
in  our  humble  opinion,  the  best  text  book  on  physiology 
in  any  land  or  language. — The  Clinic.  Nov.  6,  1875. 

As  a  whole,  we  cordially  recommend  the  work  38  a 
text-book  for  the  student,  and  as  one  of  the  best. — 
Tlie  Journal  of  Nervous  and  Menial  Disease,  Jan.  1876. 

Still  holds  its  position  as  a  masterpiece  of  lucid  writ- 
ing, and  is,  we  believe,  on  the  whole,  the  best  book  to 
place  in  the  hands  of  the  student. —  London  Students 
Journal. 


fiLA SSEN  [ALEXAND ER), 

^  Prore.<i»or  in  the.  Roynl  Polytechnic  School,  Aix  la-Chapelle. 

ELEMENTARY    QUANTITATIVE    ANALYSIS.     Translated  with 

notes    and  additions  by  Edgar  F.   Smith,   Ph.D.,  Assistant  Prof,  of  Chemistry  in  the 
Towne  Scientific  School,  Univ.  of  Penna.     In  one  handsome  royal  12mo.  volume,  of  324 
pages,  with  illustrations;  cloth,  $2  00.     {Jitst  Ready.) 
It  is  probablv  the  best  mmaal  of  an  elementary  ]  advancing  to  the  analysis  of  minerals  and  such  pro- 
nature  extant,  insomuch  as  its  methods  are  the  best,  i  dacts  as  are  met  with  in  applied  chemistry.     It  is 
It  teaches  by  examples,   commencing   with   single     an  indispensable  book  for  students  in  chemistry.— 
determinations,  followed  by  separations,  and  theu   ,  Boston  Journ.  of  Chemistry,  Oct.  1878. 


G 


ALLOWAY  [ROBERT),  F.C.S., 

Prof  of  Applied  Chemiatry  in  the  Roynl  College  of  Science  for  Ireland,  etc. 

A  MANUAL  OF  QUALITATIVE  ANALYSIS.  From  the  Fifth  Lon- 
don Edition.  In  one  neat  royal  12mo.  volume,  with  illustrations;  cloth,  $2  75.  {Lately 
Issued.) 

T>0  WMAN  [JOHN  E.) ,  M.D. 
INTRODUCTION  TO  PRACTICAL  CHEMISTRY,  INCLUDING 

ANALYSIS.  Sixth  American,  from  the  sixth  and  revised  London  edition.  With  numer- 
ous illustrations.     In  one  neat  vol.,  royal  I2mo.,  cloth,  $2  26. 
^nr  THE  SAME  AUTHOR.  

PRACTICAL  HANDBOOK  OF  MEDICAL  CHEMISTRY.    New 

edition.     In  one  neat  volume,  royal  12mo.      [Preparing.) 


T>EMSEN{IRA),  M.D.,  Ph.D., 

Professor  of  Cherrastry  in  the  Johns  Hopkins  Univer.'iity,  Bnltimore. 

PRINCIPLESOP  THEORETICAL  CFIKMISTilY.  with  speoial  reference 

to  the  Constitution  of  Chemical  Compounds.    In  one  handsome  royal  12mo.  vol.  of  over 
232  pages:  cloth,  $1  50.     (Just  Issued.) 

'OHLER  AND  FITTIG. 
OUTLINES  OF  ORGANIC  CHEMISTRY.     Translated  with  Ad- 
ditions from  the  Eighth  German  Ed.     By  Ira  Remsen,  M.D.,  Ph.D.,  Prof,  of  Chem- 
andPhysics  in  Williams  College,  Mass.  In  one  volume,  royal  12mo.of  550  pp.,  cloth,  $3. 


w 


10 


Henry  C.  Lea's  Publications — {Chemistry^. 


JpoWNES  [GEORGE],  Ph.D. 

A  MANUAL  OF  ELEMENTARY  CHEMISTRY;  Theoretical  and 

Practical.    Eevised  and  corrected  by  Henry  Watts,  B.A.,  F.R.S.,  author  of  "A  Diction- 
ary of  Chemistry,"  etc.    With  a  colored  plate,  and  one  hundred  and  seventy-seven  illus- 
trations.   A  new  American,  from  tht  twelfth  and  enlarged  London  edition.     Edited  by 
KoBEKT  Bridges,   M.D.       In   one  large  royal  12mo.   volume,   of  over   1000  pages; 
cloth,  $2  75;  leather,  $3  25.      {Just  Ready.) 
Two  careful  revisions  by  Mr.  Watts,   since  the  appearance  of  the  last  American  edition  of 
"  Fownes,"  have  so  enlarged  the  work  that  in  England  it  has  been  divided  into  two  volumes.   In 
reprinting  it,  by  the  use  of  a  small  and  exceedingly  clear  type,  cast  for  the  purpose,  it  has  been 
found  possible  to  comprise  the  vphole,  without  omission,  in  one  volume,  not  unhandy  for  study  and 
reference.   The  enlargement  of  the  work  has  induced  the  American  Editor  to  confine  his  additions 
to  the  narrowest  compass,  and  he  has  accordingly  inserted  only  such  discoveries  as  have  been  an- 
nounced since  the  very  recent  appearance  of  the  work  in  England,  and  has  added  the  standards 
in  popular  use  to  the  Decimnl  and  Centigrade  systems  employed  in  the  original. 

Among  the  additions  to  this  edition  will  be  found  a  very  handsome  colored  plate,  representing 
a  number  of  spectra  in  the  spectroscope.  Every  care  has  been  taken  in  the  typographical  execu- 
tion to  render  the  volume  worthy  in  every  respect  of  its  high  reputation  and  extended  use,  and 
though  it  has  been  enlarged  by  more  than  one  hundred  and  fifty  pages,  its  very  moderate  price 
will  still  maintain  it  as  one  of  the  cheapest  volumes  accessible  to  the  chemical  student. 

what  formidable  magnitude  with  its  more  than  a 
thousand  page?,  but  witli  less  than  this  uo  fair  repre- 
sentation of  cliemistry  as  it  now  is  can  be  given.   The 


This  work,  inorganic  and  organic,  is  complete  in 
one  convenient  volume.  In  its  earliest  editions  it 
was  fully  up  to  the  latest  advancements  and  theo- 
ries of  that  time.  In  its  present  form,  it  presents, 
in  a  remarkably  convenient  and  satisfactory  man- 
npr,  the  principles  and  leading  facts  of  the  chemistry 
of  to-day.  Concerning  the  manner  in  which  the 
various  tubjects  are  treated,  much  deserves  to  be 
said,  and  mostly,  too,  in  praise  of  the  book.  A  re- 
view of  such  a  work  ae  Fownes's  Cheini-itry  within 
the  limits  of  a  book-notice  for  a  medical  weekly  is 
simply  out  of  the  question. — Cinci'iinnti  Lancet  and 
Clinic,  D.-C.  It,  1878. 

When  we  state  that,  in  our  opinion,  the  present 
edition  sustains  in  every  respect  the  high  reputation 
which  its  predecessors  have  acquired  and  enjoyed, 
we  express  therewith  our  full  belief  in  its  intrinsic 
value  as  a  text-book  and  work  of  reference. — Am. 
Journ.  of  Pharm..,  Aug.  1878. 

The  conscientious  care  wliich  has  been  bestowed 
npon  it  by  the  American  and  English  editors  renders 
it  still,  perhaps,  the  best  book  for  the  student  and  the 
practitioner  who  would  keep  alive  the  acquisitions 
of  his  student  days.    It  has,  indeed,  reached  a  some- 


type  is  small  but  very  clear,  and  the  sections  are  very 
lucidly  arr.suged  to  facilitate  study  and  reference. — 
Me.d.  and  Surg.  Reporter,  Aug.  .3,  1878. 

The  work  is  too  well  known  to  American  students 
to  need  any  extended  notice  ;  safflce  it  to  say  that 
the  revi.-ion  by  the  English  editor  has  been  faithfully 
done,  and  that  Professor  Bridges  has  added  some 
fresh  and  valuable  matter,  especially  in  the  inor- 
ganic chemistry.  Ttie  book  has  always  been  a  fa- 
vorite in  this'  country,  and  in  its  new  shape  bids 
fair  to  retain  all  its  former  prtstige. — Boston  Jour, 
of  Chemistry,  Aug.  1878. 

It  will  be  entirely  unnecessary  for  ns  to  make  any 
remarks  relating  to  the  general  characterof  Fownes' 
Manual.  For  over  twenty  years  it  has  held  the  fore- 
most place  as  a  text-book,  and  the  elnborate  and 
thorough  revisions  which  have  been  made  from  time 
to  time  leavelittle  chance  for  any  wide  awake  rival  to 
step  before  it. — Canadian  Pliarm.  Jour.,  Aug.  1878. 

As  a  manual  of  chemistry  it  is  without  a  superior 
in  the  language. — Md.  Med.  Jour.,  Aug.  1878. 


A  TTFIELD  [JOHN),  Ph.D., 

■^-*-  Professor  of  Practical  Chemistry  to  the  Pharmaceutical  Society  of  Great  Britain,  &e. 

CHEMISTRY,  GENERAL,  MEDICAL,  AND  PHARMACEUTICAL; 

including  the  Chemistry  of  the  U.  S.  Pharmacopoeia.  A  Manual  of  the  General  Principles 
of  the  Science,  and  their  Application  to  Medicine  and  Pharmacy.  Eighth  edition  revised 
by  the  author.  In  one  handsome  royal  12mo.  volume  of  700  pages,  with  illustrations. 
Cloth,  $2  50  ;  leather,  $3  00.      (Just  Ready.) 


We  have  repeatedly  expressed  our  favorable 
opinion  of  this  work,  and  on  the  appearance  of  a 
new  edition  of  it,  little  remains  for  us  to  say,  ex- 
cept that  we  expect  this  eighth  edition  to  be  as 
indispenssble  to  us  as  the  seventh  and  previous 
editions  have  been.  While  the  general  plan  and 
arrangement  have  been  adhered  to,  new  matter 
has  been  added  covering  the  obsei'vations  made 
since  the  former  edition  The  present  difi'ers  from 
the  preceding  one  chiefly  in  these  alterations  aiid 
in  about  ten  pages  of  useful  tables  added  in  the 
appendix  —Am.  Jour,  of  J'harmacy,  May,  1S"9. 

A  standard  work  like  Attfield's  Chernistry  need 
only  be  mentioned  by  its  name,  without  furllier 
comments  The  present  edition  contains  such  al 
terations  and  additions  as  seemed  necossiory  for 
the  demonstration  of  the  latest  developments  of 
chemical  principles,  and  the  latest  applications  of 
chemistry  to  pharmacy.  The  author  has  bestowed 
arduoTB  labor  ou  the  reviKion,  and  the  ex'ent  of 
the  information  thus  iotroduced  may  be  estimated 
from  the  fact  that  the  index  contains  three  hun- 
dred new  references  relating  to  additional  mate- 
rial.—D?*»4£?£ri«<5'  Circular  and  Chemical  Gazette, 
May,  1879. 

This  very  popular  and  meritorious  work  has 
now  reached  its  eighth  edition,  which  fact  speaks 
io  the  highest  terms  in  commendation  of  its  excel 
lence.     It  has  now  become  the  principal  text-book 


of  chemistry  in  all  the  medical  colleges  in  the 
United  States.  The  present  edition  contains  such 
alterations  and  additions  as  seemed  necessary  for 
the  demonstration  of  the  latest  developments  of 
chemical  principles,  and  the  latest  applications  of 
chemistry  to  pharmacy.  It  is  scarcely  nece.'sary 
for  us  to  say  that  it  exhibits  chemistry  in  Its  pre- 
sent advanced  state. — Cincinnati  Medical  Ntws, 
April,  1879. 

The  popularity  which  this  work  has  enjoyed  la 
owing  to  the  origiual  and  clear  disposition  of  the 
facts  of  the  science,  the  accuracy  of  the  details,  and 
the  omission  of  much  which  freights  many  treatises 
hf  a vily  without  bringing  corresponding  instruction 
to  the  reader.  Dr.  Attliold  writes  for  students,  and 
primarily  for  medical  students  ;  he  always  has  an 
eye  to  the  pharmacopeia  and  its  ofllcinal  prepara- 
tions; and  he  is  continually  putting  thn  matter  in 
the  text  so  that  it  responds  to  the  questions  with 
which  each  section  is  provided.  Thus  thn  student 
learns  easily,  and  can  always  refresh  and  test  his 
knowledge.— Jl/fd  andSnrg.  Reporter,  Aprill9,"79. 

We  noticed  only  about  two  years  and  a  half  ago 
the  Dublication  of  the  preceding  edition,  and  re- 
marked upoo  the  exceptionally  valuable  character 
of  the  work.  The  work  now  iacludes  the  whole  of 
the  chemistry  of  the  ptiarniacop(i)ia  of  the  United 
States,  Groat  Britain,  and  iuiWa.— New  Remedief, 
May,  1879. 


IIenuy  C.  Lea's  Publications — (Ciiemislrij). 


11 


TjlAKQUHARSON  {ROBERT),  M.D 

Le<itureron  Materia  Mmiica  at  St.  Mary' 

A  GUIDE  TO  THERAPEUTIC 

cond  Amerioan   edition,  revised  by  the 
Phariiiiuropcoia.     By  Fhank   Woodisuuv, 
piiges  :  cloth,  $2.25.      (Just  Ready.) 
The   appi'Sirance  of  a  now  editioQ  of  this  conve- 
nient aud  handy  book  in  less  tlian  two  years  may 
certainly  lie  taken  as  au  indication  of  its  useful 
ness.     Its  cou'-euient  arrangeinont,  and  its  terse- 
ness, and,  at  the  same  tiiiie,  com oleteness  of  the 
information  given,  make  it  a  handy  book  of  refer- 
ence.— Am.  Journ.  of  Pharmacy,  June,  1S79. 

The  early  appearance  of  a  second  elition  of  Dr. 
Farqnharson's  work  bears  sufficient  testimony  to 
the  appreciation  of  it  by  American  readers.  The 
plan  is  such  as  to  bring  the  character  and  action  of 
drugs  to  the  eye  and  mind  with  clearness  The 
care  with  which  both  author  and  editor  have  done 
their  work  is  conspicuous  on  every  page  — Med.  and 
fiurff.  Reporter,  May  .'51,  1S7!». 

The  second  edition,  enlarged  and  revised,  is  a 
happy  medium  betweeu  the  first  edition,  which 
was  rather  too  brief  on  some  important  matters, 
and  the  large  octavos  of  Wood  and  Birtholow.  It  | 
is  brought  up  to  the  most  recent  researches,  one 
note  referring  to  an  article  published  in  Aoril  of 
this  year.  The  favorihle  reception  accorded  it, 
shown  by  this  reissue  in  two  years,  was  one  well 
merited.  — i/Oi;!Sui!/Z«  3Ied.  Neios,  June  7,  1S79. 


n  tl'ispital  Medical  School. 

S  AND  MATERIA  MEDICA.     Se- 

Author.     Enlarged   and  adapted  to  the  U.  S. 
,  M.D.     In  one  neat  rojal  12mo.  volume  of  498 

This  work  contains  in  moderate  compasB  soch 
well-digested  facts  concerning  the  physiological 
and  therapeutical  action  of  renedies  ai)  are  reason- 
ably established  up  to  the  present  time.  By  a  con- 
venient arrangement  the  corresponding   effects  of 

I  each  article  in  health  and  disease  are  presented  In 
parallel  columns,  not  only  rendering  reference 
easier,  but  also  impressing  the  facts  more  strongly 
upon  the  mind  of  the  reader.     The  book  has  been 

[  adapted  to  the  wants  of  the  American  student,  and 
copious  notes  have  been  introduced,  embodying  the 
latest  revision  of  tVe  I'harmacopoQia,  together  with 
the  antidotes  to  the  more  prominent  poisons,  and 
such  of  I  he  newer  remedial  agents  as  seemed  neces- 
sary f.o  the  completeness  of  the  work.  Tables  of 
weights  and  measures,  and  a  good  alphabetical  in- 
dex, end  the  volurne. — Drriggi.<its'  Circular  and 
Chemical  Gazette,  June,  1S79. 

It  is  a  pleasure  to  think  that  the  rapidity  with 
which  a  second  editiou  is  demanded  may  be  taken 
as  an  indication  that  the  sense  of  appreciation  of  the 
value  of  reliable  information  regarding  the  use  of 
remedies  i-  not  entirely  overwhelmed  in  the  cultiva- 
tion of  pathological  studies,  characteristic  of  the  pre- 
sent day.  This  work  certainly  merits  the  success  it 
has  so  quickly  achieved. — New  Reruedies,  July,  '79. 


B 


LOXAM  (C.  L.), 

Profes-ior  of  Ohemi-'ttry  in  King's  College,  London. 

CHEMISTRY,  INORGANIC  AND  ORGANIC.    From  the  Second  Lor- 

don  Edition.     In  one  very  handsome  octavo  volume,  of  700  pages,  with  about  300  illus- 
trations.    Cloth,  $4  00  ; 'leather,  $5  00.     [Lately  Issued.) 

It  would  be  difficult  for  a  practical  chemist  and 
teacher  to  fiud  any  material  fault  with  this  most  ad- 
mirable treatise.  The  author  has  given  us  almost  a 
cjclopjcdia  within  the  limits  of  a  convenient  volume, 
and  has  done  so  without  penning  the  uselefts  para- 
graphs too  commonly  making  up  a  great  part  of  the 
bulk  of  many  cumbrous  works.  The  progressive 
Scientist  is  not  disappointed  when  he  looks  for  the 
record  of  new  and  valuable  proces.'es  acd  discover- 
ies, while  the  cautious  conservative  does  not  find  its 


We  have  in  this  work  a  eompleteand  most  excel- 
lent text-book  for  the  use  of  schools,  and  can  heart- 
ily recommend  it  as  such. — Boston  Med.  and  Surg. 
Journ.,  May  2S,  1574. 

Theaboveisthetitleofawork  which  we  can  most 
conscienriously  recommend  to  students  of  chemis- 
try. It  is  as  easy  as  a  work  on  chemistry  could  be 
made,  at  thesame  time  that  it  presentsa  full  account 
of  that  science  as  it  now  stands.  We  have  spoken 


of  the  work  as  admirably  adapted  to  the  wants  of  |  ^^      monopolized  by  uncertain  theories  and  specu 


Students;  it  is  quite  as  well  suited  to  the  require- 
ments of  practitioners  who  wish  to  review  their 
chemistry,  or  have  occasion  to  refresh  their  memo- 
ries on  any  point  relating  to  it.  In  a  word,  it  is  a 
book  to  he  read  by  all  who  wish  to  know  what  is 
the  chemistry  of  the  present  day. — American  Prac- 
titioner, Nov.  1S73. 


laiions.  A  peculiar  point  of  excellence  is  the  crys- 
tallized form  of  expression  in  which  great  truths  are 
expressed  in  very  short  paragraphs.  One  is  surprised 
at  the  brief  space  allotted  to  an  important  topic,  and 
yet,  after  reading  it,  he  feels  that  little,  if  any  more 
should  have  been  said.  Altogether,  it  is  seldom  yo  c 
see  a  text-book  so  nearly  faultless.  —  Cincinnati 
Lancet,  Nov.  1S73. 


pLO  WES  (FRANK).  D.Sc.  London. 

^^  Suni'ir  Science-  Ma.i-ter  at  the  High  School,  Xewcastle-undf.r  Li/me,  etc. 

AN  ELEMENTARY  TREATISE  ON  PRACTICAL  CHEMISTRY 

AND  QUALITATIVE  INORGANIC  ANALYSIS.  Specially  adapted  for  Use  in  the 
LaVioratories  of  Schools  and  Colleges  and  by  Beginners.  From  the  Second  and  Revised 
English  Edition,  with  about  fifty  illustrations  on  wood.  In  one  very  handsome  royal 
12mo.  volume  of  372  pages:  cloth,  $2  60.      (Nou>  Ready.) 


It  is  short,  concise,  and  eminently  practical.  We 
therefore  heartily  commend  it  to  sluden's,  and  espe- 
cially to  those  who  are  oliliged  to  dispense  with  a 
master.     Of  course   a  teacher  is  in  every  wavdesi- 


are  so  simple,  and  yet  concise,  as  to  be  interesting 
and  intellig'ble.  The  work  is  unincumbered  with 
theoretical  deductions,  dealing  wholly  with  the 
practical  matter,  which  it  is  the  aim  of  this  compre- 


rable,  but  a  good  degree  of  techuics.1  skill  and  prac-     hensive  textbook  to  impart.     The  accuracy  of  the 


tical  knowledge  can  he  attained  with  no  other 
instructor  than  the  very  valuable  handbook  now 
under  consideration. — St.  Louis  Clin.  Record,  Occ. 

1877. 

The  work  is  so  written  and  arranged  that  it  can  be 
comprehended  by  the  student  within iit  a  teacher,  and 
the  descriptions  and  directions  forthe  various  work 


analytical  methods  are  vouched  for  from  the  fact 
that  they  have  all  been  worked  through  by  the 
author  and  the  members  of  his  class,  from  the 
printed  text.  We  can  heartily  recommend  the  work 
to  the  student  of  chemistry  as  being  a  reliable  ard 
comprehensive  one. — Drxiggisis'  Advertiser,  Oct. 
l.j,  1S77. 


KXiPP'S  TECHNOLOGY;  or  Chemistry  Applied  to 
the  Arts,  and  to  Manufactures.  With  American 
additions  by  Prof.  Walter  7„.  Johxson.    In  two 


very  handsome  octavo  volumes,  with  500  wood 
engravings,  cloth,  $6  00. 


12      Henry  C.  Lea's  Publications — {Mat.  Med.  and  Therapeutics). 


pARRISH  [EDWARD), 

Late  Professor  of  Materia  Medica  in  the  Philadelphia  College  of  Pharmacy. 

A  TREATISE  ON  PHARMACY.    Designed  as  a  Text-Book  for  the 

Student,  and  as  a  Guide  for  the  Physician  and  Pharmaceutist.    With  many  Formulae  and 

Prescriptions.     Fourth  Edition,  thoroughly  revised,   by  TnoMvis  S.  Wiegand.     In  one 

handsome  octavo  volume  of  977  pages,  with  280  illustrations ;  cloth.  §5  60  ;  leather,  $6  50. 

iLately  Issued.) 

Of  T)r.  Parl•i^ill's  great  -CT-ork  on  pharmacy  it  only  |  the  work,  not  only  to  pharmacists,  but  also  to  the 

remains  to  be  said  that  the  editorhas  accomplished  j  multitude  of  medical  practitioners  who  are  obliged 

his  work  so  well  as  to  maintain,  in  this  fourth  edi- 1  to  compound  their  own  medicines.    It  will  ever  hold 

tion,  the  high  standard  of  excellence  which  it  bad  ,  an  honored  place  on  our  own  bookshelves. — Dublin 

attainedin  previous  editions,  under  the  editorship  of :  Med.  Press  and  Circular,  Aug.  12,  1S74. 

its  accomplished  author.     This  has  not  been  accom- 


We  expressed  our  opinion  of  a  former  edition  in 
terms  of  unqualified  praise,  and  we  are  in  no  mood 
to  detract  from  that  opinion  in  reference  to  the  pre- 
sent edition,  the  preparation  of  which  has  fallen  into 
competent  hands.  It  is  a  book  with  which  no  pharma- 
cist can  dispense,  and  from  which  no  physician  can 
fail  to  derive  much  information  of  value  to  him  in 
practice. — Pacific  Med.  and  Surg .  Journ. ,  June, '74. 

Perhaps  one,  if  not  the  most  important  book  upon 
pharmacy  which  has  appeared  in  the  English  lan- 
guage has  emanated  from  the  transatlantic  press. 
"  Parrish's  Pharmacy"  is  a  well-known  work  on  this 
side  of  the  water,  and  the  fact  shows  us  that  a  really 
serves  a  strictly  scieniificcharacter.  The  whole  work  ;  useful  work  never  becomes  merely  local  in  its  fame. 
reflects  the  greatest  credit  on  author,  editor  and  pub-  [  Thanks  to  the  judicious  editing  of  Mr.  Wiegand,  the 
lisher.  It  will  convey  some  idea  of  the  liberality  which  1  posthumous  edition  of  "Parrish"  has  been  saved  to 
has  been  bestowed  upon  itsproducti  on  when  we  men-'  the  public  with  all  the  mature  experience  of  its  au- 
tion  thatthereare  no  less  than  2S0  carefully  executed  ,  tbor.  anri  perhaps  none  the  worse  for  a  dash  of  new 
illustrations.  In  conclusion,  we  heartily  recommend  '  blood. — Loud.  Phartn.  Journal,  Oct.  17,  1874. 


plished  without  much  labor, and  many  additions  and 
improvements,  involving  changes  in  the  arrange- 
mentnfthe  several  parts  of  the  work,  andtheaddi- 
tion  of  much  new  matter.  With  the  modifications 
thus  effected  it  constitutes,  as  now  presented,  a  com- 
pendium of  the  science  and  art  indi.'pensable  to  the 
pharmacist,  and  of  the  utmost  value  to  every 
practitioner  of  medicine  desirous  of  familiarizing 
himself  with  the  pharmaceutical  preparation  of  the 
articles  which  he  prescribes  for  bis  patients. — Chi- 
ca.go  Med.  Journ.,  July,  1S74. 

The  work  is  eminently  prartical,  and  has  the  rare 
merit  of  being  readable  and  interesting,  while  it  pre 


^TILLE  [ALFRED),  M.D., 

Professor  of  Theory  and  Practice  of  Medicinein  the  University  of  Penna. 

THERAPEUTICS  AND  MATERIA  MEDICA ;  a  Systematic  Treatise 

on  the  Action  and  Uses  of  Medicinal  Agents,  including  their  Description  and  History. 
Fourth  edition,  revised  and  enlarged.  In  two  large  and  handsome  8vo.  vols,  of  about  2000 
pages.     Cloth,  $10;  leather,  $12.     {Lately  Isstied.) 
It  is  unnecessary  to  do  much  more  than  to  an-    of  the  present  edition,  a  whole  cyclopsedia  of  thera- 
nouncethe  appearance^  of  the  fourth^edition  of  this  j  peutics. —  Cfticap'o  Medical  Journal,  Feh.  1875. 

The  rapid  exhaustion  of  three  editions  and  the  uni- 
versal favor  with  which  the  work  has  been  received 


-Brit,  and  For. 


by  the  medical  profest-ion,  are  sufiicient  proof  of  its 
excellence  as  a  repertory  of  practical  and  usefulin- 
formation  for  the  physician.    The  edition  before  us 


well  known  and   excllent  work, 
Med.-Ghir.  Review,  Oct  lb7.5. 

For  all  who  desire  a  complete  work  on  therapeutics 
and  materia  medica  for  reference,  in  cases  involving 
medico-legal  questions,  as  well  as  for  information 

concerning  remedial  agents,  Dr.Still6'sis  '■'■'par  ex-  j  fully  sustains  this  verdict,  as  the  work  has  been  care- 
celleiice"  the  work.  The  work  being  out  of  print,  by  I  fully  revised  andin  some  portions  rewritten,  briug- 
iheexhaustion  of  former  editions,  theauthorhas  laid  '  ing  it  up  to  the  present  time  by  the  admission  of 
the  profession  under  renewed  obligations,  by  the  ■  chloral  and  croton  chloral,  nitrite  of  amyl,  bichlo- 
carefiil  revision,  importantadditions,  and  timely  re  i  ride  of  methylene,  methylic  ether,  lithium  com- 
issuing  a  work  not  exactly  supplemented  by  any  |  pounds,  gelseminnm,  and  other  remedies. — Ain. 
other  in  the  English  language,  if  in  any  language,  j  Journ.  of  Pharmacy,  Feb.  1875. 


The  mechanical  execution  handsomely  sustains  the 
well-known  skill  and  good  taste  of  the  publisher. — 
St.  Louis  Med.  and  Surg.  Journal,  Dec.  1874. 

From  the  publication  of  the  first  edition  "Still6's 
Therapeutics"  has  been  one  of  the  classics;  its  ab- 
sence from  our  libraries  would  create  a  vacuum 
which  could  be  filled  by  no  other  work  in  the  lan- 
guage, and  its  presence  supplies,  in  the  two  volumes 


We  can  hardly  admit  that  it  has  a  rival  in  the 
multitnde  of  its  citations  and  the  fulness  of  its  re- 
search into  clinical  histories,  and  we  must  assign  it 
a  place  in  the  physician's  library;  not,  indeed,  as 
fully  representing  the  present  state  of  knowledge  in 
pharmacodynamics,  but  as  by  far  the  most  complete 
treatise  upon  the  clinical  and  practical  side  of  the 
question. — Boston  Med.  and.  Sicrg.  Journal,  Nov.  5, 
1874. 


QRIFFITH  [ROBERT  E.),  M.D. 

A  UNIVERSAL  FORMULARY,  Containing  the  Methods  of  Prepar- 
ing and  Administering  Officinal  and  other  Medicines.  The  whole  adapted  to  Physicians  and 
Pharmaceutists.  Third  edition,  thoroughly  revised,  with  numerous  additions,  bj  John  M. 
Maisch,  Professorof  Materia  Medica  in  the  Philadelphia  College  of  Pharmacy.  In  one  large 
andhandsome  octavovolumeof  aboutSOOpp.,  cl.,  $450  ;  leather,  $5  50.  {Lately  Issued.) 
To  the  druggist  a  good  formulary  is  simply  indis- 1  A  more  complete  formulary  than  it  is  in  its  pres- 
pensablo,  and  perhaps  no  formulary  has  been  more  |  enf  form  the  pharmacist  or  physician  could  hardly 


extensively  used  than  the  well-known  work  before 
ns.  Many  physicians  have  toofflciate,  also,  as  drug- 
gists. This  is  true  especially  of  the  country  physi- 
cian, and  a  work  which  shall  teach  him  the  means 
by  which  to  administer  or  combine  his  remedies  in 
the  most  elBcacious  and  pleasant  manner,  will  al 


iesire.  To  the  first  some  such  work  is  indispensa- 
ble, and  it  is  hardly  less  essential  to  the  practitioner 
who  compounds  his  own  medicines.  Much  of  what 
is  contained  in  the  introduction  ought  to  be  cora- 
rnitled  to  memory  by  every  student  of  medicine. 
As  a  help  to  physicians  it  will  be  found  invMluable, 


ways  hold  its  place  upon  his  shelf  A  formulary  of  1  and  doubtless  will  make  its  way  into  libraries  not 
this  kind  is  of  benefit  also  to  the  city  physician  in  j  already  supplied  with  a  standard  work  of  the  kind, 
largest  practice.— Cincinnati  Clinic,  Feb.  21,  1874.  —The  Arnnrican  Pracliliont.r,  LoMiaviUe,  Jn\y,"!4. 


Henry  C.  Lea's  Publications — {Mat.  Me.d.  and  Therajyeulics.)      13 
CfTILLE  [ALFRED),  M.D,  LL.D.,  and   TfAlSCH  {JOHN  M.),  Ph.D., 

*J        Pm/  of  Theory  iind  Prnctiri' of  Moilicine  -L^L        Prof,  of  ^fnt.  Me'i.  find  Rot  in  Phila. 

and  of  Clinical  Med.  in  Univ.  of  Pa.  Coll.  Phnrmiicy,Hfc;i  to  the.  Ame.ricnn 

Phnrmace.nlicut  AsMocifUlon. 

THE   NATIONAL  DISPENSATORY:  Containitifr  the  Natural  History, 

Chemistry,  Pharmacy,  Actions  and  Uses  of  Medicines,  including  those  recognized  in 
the  Pharm;icopoeia.«  of  the  United  St:ites  and  Great  Britain.  In  one  very  hanHsorae 
octavo  volume  of  1G28  pages,  with  over  200  illustrations.  Extra  cloth,  $6  75;  leather, 
raised  bands,  $7  50.      {Now  Reaily  ) 

EXTRACT  FROM  THE  PREFACE, 

"  In  the  rapid  progress  of  modern  research,  few  subjects  have  of  late  years  received  greater  acces- 
sions of  fact.s  than  the  group  of  science.-i  connected  with  materia  meiliea  and  therapeutics.  The 
new  re.'^ources  thus  placed  at  the  eouiinand  of  the  pharmaceutist  and  physician  have  seemed  to  the 
authors  lo  justify  ;m  .'ittempt  to  make,  from  the  .ndvanced  stand-poini  of  the  present  day,  a  concise 
but  complete  statement  of  all  that  is  of  pr;iciical  importance  to  both  professions — a  digest  in  which 
that  which  is  old  and  that  which  is  new  shall  be  so  brought  together  as  to  give  to  the  reader,  within 
the  most  moderate  practicable  compass,  all  the  details  in  pharmacology,  pharmacy,  and  thera- 
peutics, which  he  is  likely  to  need  in  his  daily  avocations.  In  the  almost  infinite  accumulation  of 
material,  this  has  required  a  careful  and  conscientious  sifting  to  discard  that  which  i.s  obsolete, 
untrustworthy,  or  comparatively  trivial,  without  impairing  the  practical  completeness  of  the 
work.  Thnt  they  have  wholly  accomplished  their  object  the  authors  do  not  venture  to  claim  ;  but 
they  can  say  that  years  of  constant  labor  have  been  devoted  to  the  task  of  producing  a  work  to 
which  the  inquirer  may  refer  with  the  certainty  of  finding  everything  which  experience  has  stored 
up  as  worthy  of  confidence  in  the  subjects  embraced  within  its  scope." 

We  iDteod  to  diaw  the  attention  of  our  brother  the  preface,  and  now  that  it  has  been  published  and 
pharmacist-s  to  this  pnblicalioD,  which  cannot  fail  opens  to  ns  it.-*  vast  st<jre»  of  iuformaiion,  we  may 
to  exercise  a  widespread  and  mai  kedinliuence  upon  add  that  it  was  almost  a  neces^itv  ;  and  this  we  tay 
the  discharae  of  the  duties  of  their  vocation,  "l  he  wiiliout  meaning  to  impugn  the  great  excellence  of 
material  embodied  in  the  work  is  truly  immense,  the  works  of  sim.lar  characterti  hich  hare  preceded 
as  shown  alone  by  the  almost  countle-s  number  .  f  it.  All  of  the  descripiions,  whether  medical,  botan- 
Bubjects  treated.  We  c  mgratulale  theauthors  upon  ical,  or  pharmaceutical,  are  clear,  in  gofid  Engli-sh, 
their  suoces<  in  having  brought  to  a  close  a  work  and  unencambered  witli  oh..;oleie  and  uiiiitelligible 
which  must  inevitably  take  its  place  as  one  of  the  terms.  Those  portions  which  have  reference  to 
most  important  con  ri  butions  to  medical  and  phar-  ;  therapeutics  form  a  convenient  treatise  on  that  snb- 
maceutical  literature.  —  .4m.  Journ.  o/  P/tarm  ,  ject,  and  are  made  the  more  valuable  and  available 
May,  1S7.9.  j  by   a   complete   therapeutical    index.     The  purely 

„.  ...         .        ,     , ,        .,  i  pharmacal  pait  is  as  perfect  as  it  is  possible  to  make 

The  asfocia  :oB  of  such  distinguished  authors  as  ;  it^  a^d  i^g.,  g^uld  not  have  been  expected  when  we 
Professors  &II1K- and  Mai.ch  in  the  composition  .  f  a  :  consider  Prof.  Maisch's  great  qualifications  for  work 
work  of  this  character  has  excited  the  strong  st  in-  ,  of  that  kind.— iV.  C  Mtd.  Journ.,  Alarch,  ls79. 
terest  and  the  highest  expectati<  ns  in  the  mind  of; 

every  physician  and  pharmacist  in  the  couniry.  The  therapeutic  part  is  as  rich  as  would  be  ex- 
For  once  we  can  truly  s^ythat  the  promise  of  ex-  pectedof  the  author  of  the  most  comprehensive  work 
cellence  ha ,  been  lu  filled  to  the  letter,  and  the  Xa-  on  the  subject  in  our  language.  Tne  phy..jiological 
tional  Dispen-satory  has  come  almost  perfect  from  effects  of  drugs  receive  due  aitention,  aud  their  iu- 
the  hands  of  its  makers  The  entire  work  is  a  most  fluence  over  disease  is  slated  succinctly.  For  the 
excellent  one  and  cannot  fail  to  satisfy  the  pur-  ta.-k  of  winnowing  the  immense  accumulation  of 
chaser.  We  can  conscientious  y  recommend  it  ti  periodical  literature,  the  experience  and  matured 
every  student  and  practitioner  of  medicine  and  judgment  of  Prof.  Stille  were  emiuenly  fitted.  No 
pharmacy. — St.  Louifs  Clinical  Record,  Apr   1879.      pharmacist  or  doctor  will  repent  the  purchase  of  a 

This  magnificent  work  has  at  last  arrived,  and  ^"^"^  which  is  at  once  a  treasury  of  facts  and  the 
we  are  at  a  loss  for  words  to  express  our  apprecia-  ajeest  of  a  deciMon  of  a  high  court. -Xowi»tt7/e  J/e<i. 
tionand  togiie  our  readers  an  idea  of  it      The  sub-  1  ■"'^''**.  March  29,  lb/9. 

jeit-matteris  brought  to  date,  showing  that  it  has  The  pharmaceutical  world  has  for  a  long  time 
been  the  unceasing  aim  of  the  authors  to  supply  a  been  ou  the  gwiuu-^  in  expects  tion  of  the  foi-rhcom- 
much  needed  book,  one  that  will  contain  all  the  im-  ;„_,  Di.-pensatory  by  Prof.s.  StiUe  and  Mai.^ch,  who 
portant  facts, and  not  dwell  upon  points  that  are  of  have  acquired  mch  a  reputation  in  their  re^pective 
comparatively  little  interest  to  any  but  a  specially  Departments  that  nothing  but  a  satisfactory  work 
interested  student  While  this  work,  on  account  of  c„uld  be  expected  ;  this  expectation  has  been  quite 
Us  conci-eness,  18  adapted  to  the  pharmacal  student,  realized.  We  have  examined  the  work  with  8.,me 
It  18  equally  adapted  to  the  medical  student  aod  i  care,  aud  are  veiy  m.ich  pleased  that  we  can  pro- 
practitioner  by  us  weU  arranged  therapeutical  in-  bounce  it  to  be  reliable,  c  mprehensive,  aud  inclad- 
dexcontainingabout3(.T0releiences,  while  the  ma-  jng  the  latest  researches  available  to  us  authors, 
teria  medica  index  embraces  about  10  400  The  This  is  ra. re  particularly  true  as  regards  the  portion 
physician  sees  at  a  gUnce  all  medicines  thaj-  are  devoted  to  pharmaceutical  subjects.  We  are  fully 
used  foranycertainclassofdisease.-CAlcaflroPftar-  justified  in  stating  that  U  is,  taken  altogether.  o..e 
macist  and  Chemist.  Apr.l,  ]S,9.  j  ^f  the  most  important  and  creditable  punlicationa 

The  present  Dispensatory  is  arranged  in  alpha-  [  which  have  of  late  beeu  issued  by  the  American 
betical  order  from  the  commencement,  the  recent  press.  It  will  be  an  indispensable  reterence  book 
bdvances  in  chemistry  are  mentioned,  and  an  effort  both  for  the  pharmacist  and  the  physician. — New 
made  to  include  the  late  novelties  in  the  review  of    Remedien,  April,  1879. 

'''•!,!'?i?7''^*  "i  ""^  Phy«i=i^n:  This  is  carried  out  ;  a  careful  examinalion  of  the  work  calls  forth  un- 
with  that  sound  conservative  judgment  which  cha-  (jnalified  prai.se  for  its  excellent  arrangement,  full 
rac  erizes  all  Prof  i,t.lle  8  work.  The  chemical  ^g,  concise  information,  its  careful  adherence  to  the 
and  pharmaceutical  secuons  have  we  may  suppose,  best  autho.itv  on  each  particular  topic,  as  well  as 
received  t^.e  e.special  care  of  Prof  Maisch  ;  aad  as  the  entire  el, roi.ation  of  all  UDnece..s.r;  and  obso- 
he  is  f^i^ile  priaceps  in  that  branch,  nothing  can  be  j^te  data  and  particulars.  The  arrangement  of  all 
Tottt  \V^.'^^^%T  P'-^"*«-^«'^-  and  Surg. Re.  topics  is  purely  alphabetical,  and  wifh  surprising 
porter  Apru  .j,  is/y.  I  fidelity  to  the  wants  both  of  the  physician  and  phar- 

It  has  been  prepared  by  two  gentlemen  whose  \  macentist.  New  remedies  which  have  come  into 
learning  fully  qualified  thern  for  the  difficult  task,  ^  recent  use  are  here  lound  noticed,  with  such  facts 
and  wh  ise  eminence  entitles  them  to  be  heard  with  |  as  have  been  collated  from  careful  investigation.— 
the  respect  and  attention  due  to  authority.  The  !  Driiggialii'  Circular  and  Chemical  Gazelle,  March, 
"raison  d'etre"  of  the  book  is  modestly  stated  ia  \  1879. 


u 


Henry  C.  Lea's  Publications — {Pathology^  d:c.). 


fJORNIL  (F.),  AND  JANVIER  [L.), 

Prof,  in  the  Faculty  of  Med  ,  Paris.  Prof,  in  the  College  of  France. 

MANUAL  OF  PATHOLOGICAL  HISTOLOGY.     Translated,  with 

Notes  and  Additions,  byE.  0.  Shakespeare,  M.D.,  Pathologist  and  Ophthalmic  Surgeon 
to  Phihida.  Hospital,  Lecturer  on  Refrpction  and  Operative  Ophthalmic  Surgery  in  L'niv. 
of  Penna.,  and  by  Henry  C.  Simes.  M  D.,  Deraonstratr r  of  Pathological  Histology  in 
the  Univ.  of  Pa.         In  one  very  handsome  octavo  volume  of  about  600  pages,  with  over 
300  illustrations,      [tikortly.) 
So  much  has  been  done  of  late  years  in  the  elucidation  of  pathology  by  means  of  the  micro- 
.scope,  and  this  subject  now  occupies  so  prominent  a  pusition  as  one  of  the  most  important  branches 
of  medical  science,  that  the  American  profession  cannot  fail  to  welcome  a  translation  of  the  pre- 
.«ent  work,  which,  through  its  own   merits  and  through  the  well-known  reputation  of  its  distin- 
guished authors,  is  regarded  in  Europe  as  the  standard  text-book  and  work  of  reference  in  its 
department.   Such  investigations  and  discoveries  as  have  been  made  since  its  appearance  will  be 
introduced  by  the  translator,  and  the  work  is  confidently  expected  to  assume  in  this  country  the 
same  position  which  has  been  so  universally  accorded  to  it  abroad. 


PENWICK  {SAMUEL),  M.D., 

-*-  Assistant  Phy.tician  to  the  London  Ho.^pitnl. 

THE  STUDENT'S  GUIDE  TO  MEDICAL  DIAGNOSIS.     From  the 

Third  Revised  and  Enlarged  English  Edition.  With  eighty-four  illustrations  on  ■wood. 
In  one  very  handsome  volume,  royal  I2mo. ,  cloth,  $2  25.  {Jzist  Issued.) 
Of  the  m^iny  guid'^-'books  on  medical  din.gDO!>is,  are  few  books  of  thi.ssizeou  practical  medicine  that 
claimed  to  be  written  for  the  special  instruction  of  I  contain  so  much  and  convey  it  so  well  as  (he  volume 
students,  this  is  the  best.  The  author  is  evidently  a  before  us.  It  is  a  book  we  can  sincerely  recommend 
well-read  and  accomplished  physician. and  he  knows  '  to  the  student  fir  direct  instruction,  and  to  tbe|prac- 
how  to  teach  practical  medicine.  The  charm  of  sim-  ;  titioner  as  a  ready  and  useful  aid  to  his  memorj . — 
ptlcityisnot  theleast  intprestingfeatiirein  the  man- j  Am.  Jo  urn.  of  Syphilo  graphy ,  Jan.  lS7i. 
ner  in  which  Dr.  Fenwick  conveys  instruction.  There  ' 


G 


REEN  [T.  HENRY),  M.D., 

Lecturer  on  Pathology  and  Morhid  Anatomy  at  Oharing-Oross  Hospital  Medical  School,  etc. 

PATHOLOGY  AND  MORBID  ANATOMY.    Third  American. from 


the  Fourth  and  Enlarged  and  Revised 
volume  of  332  pages,  with  132  illustrat 

This  is  unquestionably  one  of  the  best  manuals  on 
the  subject  of  pathology  and  morbid  anatomy  that 
can  be  placed  in  the  student's  liaod.?,  and  we  are 
glad  to  see  it  kept  up  to  the  times  by  new  editions. 
Each  edition  is  carefully  revi-ed  by  the  author,  with 
the  view  of  rnakiug  it  include  the  most  recent  ad- 
vances in  pathology,  and  of  omitting  whatever  may 
have  become  obsolete.— ^'■.  ¥.  Med.  Jour.,  Feb.  1879. 

The  treatise  of  Dr.  Green  is  compact,  clearly  ex- 
pressf  d,  up  to  the  times,  and  popular  as  a  text-book, 
both  in  England  and  America.     The  cuts  are  sufS- 


English  Edition.     In  one  very  handsome  octavo 

;ions ;  cloth,  $2  25.  (Just  Ready.) 
ciently  numerous,  and  usual  y  well  made.  In  the 
p;'e>ent  edition,  such  new  matter  has  been  added  as 
was  necessary  to  enjbrace  the  later  results  iu  patho- 
logical research.  Xo  doubt  it  will  continue  to  enjoy 
the  favor  it  has  received  at  the  hands  of  the  profes- 
sion.— Med  and  Surg.  lieporfer,  Feb.  1,  1S79. 

For  practical,  ordinary  daily  u^e.  this  is  undoubt- 
edly the  best  treatise  that  is  offered  to  students  of 
pathology  and  morbid  anatomy. — Cincinnati  Lan- 
cet and  Clinic,  Feb.  S,  1S79. 


D 


AVIS  {NATHAN  S.), 

Prof,  of  PrincipUs  and.  Practice  of  Medicine,  etc.,  in  Chicago  Med.  College. 

CLINICAL  LECTURES  ON  VARIOUS  IMPORTANT  DISEASES; 

being  acollection  of  the  Clinical  Lectures  delivered  in  the  Medical  Wards  of  Mercy  Hos- 
pital, Chicago.  Edited  by  Frank  H.  Davis,  M.D.  Second  edition,  enlarged.  In  one 
handsome  royal  12mo.  volume.     Cloth,  $1  75.      {Lately  Issued.) 


WHAT  TO  OBSERVE  ATTHE  BEDSIDE  AND  AFTER 
De.\th  in  Medical  Cases.  From  the  second  Lon- 
don edition.     1  vol   royal  12mo.,  cloth.     ^100. 

CHRISTISOX'S  DISPENSATORT.  With  copious  ad- 
ditions, and  213  large  wood  engravings.  By  K. 
EOLESFIELD  GllIFFITlI,  JI.D.  One  vol.  8vo.,  pp. 
If.OO,  cloth.    *4  00. 

CARPENTER'S  PRIZE  ESSAY  ON  THE  USE  OF 
Alcoholic  Liqcors  in  Health  and  Disease.  Ne-w 
edition,  with  a  Preface  by  D.  F.  Condie,  M.D.,  and 
explanationsof  scientificwords.  In  oneneatl2mr. 
volume,  pp.  178,  cloth.    60  cents. 

GLUGE'S  ATLAS  OF  PATHOLOGICAL  HISTOLOGY 
Translated,  with  Notes  and  Additinns,  by  .Ioseph 
Leioy,  M.  D.  In  one  volume,  very  large  imperial 
quarto,  with  320  copper-plate  figures,  plain  and 
colored,  cloth.  *4  00. 
■  LA  ROCHE  ON  YELLOW  FEVER. considered  in  its 
Historical,  Pathological,  Etiological,  and  Thera 
peutical  Relations,  in  two  large  and  handsome 
octavo  volumes  of  nearly  l.'JOO  pp  ,  cloth.    $7  00. 

HOLLAND'S  MEDICAL  NOTES  AND  REFLEC- 
TIONS.   1  vol.  8vo.,  pp.  .500,  cloth.    $3  50. 


BARLOW'S  MANUAL  OF  THE  PRACTICE  OF 
MEDICINE.  With  Additions  by  D.  F.  Condif, 
M    D.     1  vol.  Svo.,  pp.  600,  cloth.     $2  50. 

TODD'SCLINICAL  LECTURES  ox  CERTAIN  ACUTB 
Diseases.  In  one  neat  octavo  volume,  of  320  pp  , 
cloth.    $2  50. 

STURGES'S  INTRODUCTION  TO  THE  STUDY  OF 
CLINICAL  MEDICI.\E.  Being  a  Guide  to  the  In- 
vestigation of  Disease.  In  one  handsome  ll!iiio. 
volume,  cloth,  ^l  2.5.    {Lately  Issued.) 

STOKES'  LECTURES  ON  FEVER.  Edited  by  John 
William  Moorh,  M.  D.,  Assistant  Physician  to  the 
Cork  Street  Fever  Hospital.  In  one  neat  Svo. 
volume,  cloth,  ••ii2  00.     {Just  Issued.) 

THE  CYCLOPAEDIA  OP  PR.\CTICAL  MEDICINE: 
comprising  Treatises  on  the  Nature  and  Treatment 
of  Diseases,  Materia  Medica  and  Therapeutics,  Dis- 
eases of  Women  and  Children,  l\Iedical  Jurispru- 
dence, etc.  etc.  By  Du.shlison,  FoRnrs,  Twkudiij, 
and  Co.NOLLV.  In  four  lar.ge  super-royal  octavo 
volumes,  of  3-2.')I  double-coluiinied  p-ige",  strongly 
aud  handsomely  bound  in  leather,  ^\:>;  cloth,  $11. 


TTenry  C.  Lea's  Publications — {Practice  of  Medicine). 


15 


L^LINT  [A  USTIN),  M.D., 

^  ProftKfior  of  the  Principles  and  Practice,  of  Medicine  in  Bellevue  Med.  College,  N   Y. 

A   TREATISE    ON   THE    PRINCIPLES  AND    PRACTICE    OF 

MEDICINE  ;   designed  for  the  use  of  Students  and  Practitioners  of  Medicine.     Fourth 
edition,  revised  and  enlarged.     In  one  large  and  closely  printed  octavo  volume  of  al)out 
IIUU  pp.;  oloth,  $6  00  ;  orstrongly  bound  in  leather,  with  raised  bands,  $7  00.     {.Lately 
Issued. ) 
By  common  consent  of  the  English  and  American  medical  pre.is,  this  work  has  been  as.signed 
to  the  highest  position  as  a  complete  and  compendiou.s  text-book  on  the  mo.st  advanced  condi- 
tion of  medical  science.     At  the  very  moderate  price  at  which  it  is  offered  it  will  be  found  one 
of  the  cheapest  volumes  now  before  the  profession. 

This  excrfUi'ut  treati.«e  ou  medicine  liiis  aeiiuivtd  Ilis  own  clinical  stndifs  and  the  latofit  contriJ)u- 
lor  itself  ia  the  ITnited  States  a  reputation  similar  to  ti on.'-  to  MifidiCiil  lilenit  in  p  hoih  iu  lliio  country  and 
that  enjoyed  in  Kngland  by  the  admirable  lectures  in  Europe,  have  received  careful  attenlion,  so  that 
of  Sir  Thomas  Watson.  We  have  referred  to  many  I  some  portions  have  been  entirely  rewritten,  and 
of  the  most  important  chapters,  and  find  the  re?!-  ]  about  seventy  pages  of  new  matter  have  been  ad- 


sion  spoken  of  in  the  preface  is  a  genuine  one,  and 
that  the  author  has  very  fairly  brought  up  his  mailer 
to  the  level  oft  lie  knowledge  of  the  present  day.  The 
work  hasthisgreatrecommeudatiou.thalit  isin  one 
volume,  and  therefore  will  not  be  so  terrifying  to  the 
student  as  the  bulky  volumes  which  several  of  our 
English  text-books  ofraedicine  havedeveloped  into. 
—  Britisli  and  Fm-^ffn  Med.-Ohir.  Kev.,  Jan.  187/'. 
It  is  of  course  unnecessary  tointroduce  or  eulogize 
this    now  standard   treatise.     The   present  edition 


ded.  —  Ohicogn  Mtd  Jour.,  June,  1873. 

Has  never  been  surpassed  as  a  text-book  for  stu- 
dents and  a  book  of  ready  reference  for  practition- 
ers. Theforce  of  its  logic,  its  simple  and  practical 
teachings,  have  left  it  without  a  rival  in  the  field. 
N.  Y.—Med.  Record,  Sept.  15,  1874. 

It  is  given  to  very  few  men  to  tread  in  the  steps  Of 
Ausiin  Klint,  whose  single  volume  on  medicine 
though  here  and  there  defective,  is  a  masterpiece  oj- 


has  been  enlarged   and  revised  to  bring  it  up  to  the  I  lucid  condensation  and  of  general  grasp  of  an  enor. 
author's  present  level  of  experience  and  reading.  '  mously  widesubject. — Lond.  Practitioner, Dec^lS 


pr  THE  SAME  AUTHOR. 

CLINICAL  MEDICINE;    a  Systematic   Treatise  on    tlie  Diagnosis 

and  Treatment  of  Diseases.  Defi£;ned  for  Students  nnd  Practitioners  of  Medicine.  In 
one  large  and  handsome  octavo  volume  of  about  900  pages.  {I/i  Pyess.) 
It  has  been  the  object  of  the  author  in  this  volume  to  present  the  science  and  art  of  medicine 
in  their  most  practical  aspect,  adapted  to  the  neoepsities  of  the  student  and  physician  in  the 
daily  routine  of  duties  at  the  bedside.  By  avoiding  the  discussion  of  questions  relating  to 
pathology  and  etiology,  space  is  gained  for  the  thorough  consideration  of  diagnosis  and  treat- 
ment, embracing  many  points  which  escape  attention  in  the  ordinary  textbooks.  In  the  arrange- 
ment of  the  work,  diseases  are  classed  according  to  the  system  of  organs  primarily  affected  ;  and 
affections  closely  related  are  grouped  together  so  as  to  elucidate  their  differentiation,  and  the 
appropriate  treatment  is  pointed  out  for  each.  The  preparation  of  the  work  has  occupied  the 
author  for  several  years,  and  is  presented  as  embodying  the  results  of  prolonged  observation  and 
e.^cperience  under  opportunities  more  extensipe  than  often  fall  to  the  lot  of  the  physician. 


jgY  THE  SAME  AUTHOR. 

ESSAYS    ON    CONSERVATIVE   MEDICINE    AND    KINDRED 

TOPICS.     In  one  very  handsome  royal  12mo.  volume.     Cloth,  $1  38.     {Just  Issued.) 
TJARTSHORNE  {HENRY),  M.D., 

•*-*■  PrnfesHor  of  Hygiene  in  the  University  of  Penn.^ylvania. 

ESSENTIALS  OF  THE  PRINCIPLES  AND  PRACTICE  OF  MED  I- 

CINE.  A  handy-book  forStudents  and  Practitioners.  Fourth  edition,  revised  and  im- 
proved. With  about  one  hundred  illustrations.  In  one  handsome  royal  ]2mo.  volume, 
of  about  550  pages,  cloth,  $2  63  ;   half  bound,  $2  88.      (Lately  Issued.) 


Asa  handbook,  which  clearly  sets  fortli  the  e.ssen- 

TI.AI.S  of  the  PKINCIPI.ES  AND  PRACTICE  op    .MEDICINE, 

we  do  not  know  of  its  equal.—  Va.  Med.  Monthly. 
As  a  brief,  condensed,  but  comprehensive  hand- 


book, it  cannot  be  improved  upon. 
Examiner,  Nov.  I'j,  1  S74 


-Chicago  Med. 


Without  doubt  the  best  book  ofthe  kind  published 
in  the  English  languagB. — St.  Louis  Med.  and  Surg. 
Joiirn  ,  Nov.  1874. 


^ATSON  [THOMAS),  M.D.,  ^c. 

LECTURES    ON    THE     PRINCIPLES    AND    PRACTICE    OF 

PHYSIO.    Delivered  at  King's  College,  London.     A  new  American,  from  the  Fifth  re- 
vised and  enlarged  English  edition.   Edited,  with  additions,  and  several  hundred  illustra- 
tions, by  Henry  Hartshorne,  M.D.,  Professor  of  Hygiene  in  the   University  of  Pen^ 
sylvania.     In  two  large  and  handsome  8vo.  vols.    Cloth,  $9  00  ;  leather,  $11  00.     {Lately 
Published.) 
Itisasubject  for  congratulation  and  for  thank-    cate  and  Important  pathological  and  practical  ques- 
ful  lessthat  Sir  Thomas  Watson, during  a  period  of    tions,  the  results  of  his  clear  insight  and  his  calm 
coiujarative  leisure,   after  a   long,  laborious,  and    judgment  are  now  recorded  for  the  benefif  of  mun- 
inost  aonorableprofessional  career,  while  retaining    kind,  in  language  which,  for  iirecision,  vigor,  and 
full  possession  of  his  high  mental  faculties,  should    classical  elegance,  has  rarely  been    e(jualled,  and 
have  employed  the  opportunity  to  submit  his  Lee-    never  surpassed      The  revision  has  evidently  been 
tures  toa  more  thorough  revisionthan  was  possible  ,  most  carefully  done,  and  the  results  appear  in  a1- 
during  the   earlier  and   busier  period  of  his   life.    mOBt  every  page. — Brit.  Med.  fourn.,  Oct.  li,\S71. 
Carefully  passing  in  review  some  of  the  most  intri-  i 


16 


Henry  C.  Lea's  Publications — {Practice  of  Medicine). 


JDRISTO  WE  [JOHN-  SYER),  M.D..  F.R.C.F., 

uD  Physician  and  Joint  Lecturer  on  Medicine,  St.  Thomas's  Hospital. 

A  MANUAL  OX  THE  PRACTICE  OF  MEDICINE.    Edited,  with 

Additions,  by  James  H.  IIutchinsos,  M.D.,  Physician  to  the  Penna.  Hospital.  In  one 
handsome  octavo  volume  of  over  1100  pages  :  cloth,  $5  50;  leather,  $6  50.  (Just  Issued.) 
This  portly  volume  is  a  model  of  condensation.  <  incrensed  by   the  judicious   notes  of  the  Editor. — 


In  a  style  at  once  clear,  interesting,  and  concise,  Dr. 
Bristowe  passes  in  review  every  conceivable  subject 
counected  wilh  tlie  practice  of  medicine.  Those 
practitioners  who  purchase  few  books  will  find  this 
a  most  opportune  publication,  because  so  many  top- 


Cinciannti  Clinic,  Jan.  7,  1877. 

Any  one  who  wants  a  good,  clear,  condensed  work 
upon  Practice,  quite  up  with  the  most  recent  views  in 
pathology,  will  find  this  a  most  valuable  work.  The 
additions  made  by  Dr.  Hutchinson  are  appropiiate 


ic*  not  usually  embraced  in  a  work  on  practice  are     and  useful,  andso  well  done  that  wewi>h  there  were 
adequately  handled.     Thebookis  a  thoroughly  g.'od     more  of  them.— zlw.  Practitioner,  Feb.  1S77 
one,  and  its  usefulness  to  American  readers  has  been 


irrOODBURY  {FRANK),  M.D., 

Phy-ncian  to  the  German  Hospital,  Philadelphia,  late  Chief  Assist,  to  Med.  Clinic,  Jeff.  College 
Hospital,  etc. 

A    HANDBOOK   OF    THE    PRINCIPLES   AND    PRACTICE    OF 

Medicine  •   for  the  use  of  Students  and  Practitioners.     Based  upon  Husband's  Handbook 
of  Practice.     In  one  neat  volume,  royal  12mo.      {In  Press.) 


TJABERSHON  [S.  0.).  M.D 


Senior  Phy.s-ieian  to  and  late  Lecturer  on  the  Principles  and  Practice  of  Medicine  at  Guy's 
Hospital,  etc. 

ON  THE  DISEASES  OF  THE  ABDOMEN,  COMPRISING  THOSE 

of  the  Stomach,  and  other  parts  of  the  Alimentary  Canal,  Oesophagus,  Caecum,  Intes- 
tines, and  Peritoneum.  Second  American,  from  the  third  enlarged  and  revised  Eng- 
lish edition.  With  illustrations.  In  one  handsome  octavo  volume  of  over  500  pages. 
Cloth,  $3  50.      (Noz'j  Ready.) 

This  work  has  remained  sime  time  out  of  print,  owing  to  the  careful  and  conscientious 
revision  which  it  has  enjoyed  at  the  hands  of  the  author,  and  which  has  nearly  doubled  its 
size  since  the  appearance  of  the  first  edition.  Yet  there  is  no  work  accessible  to  the  profession 
to  take  its  place,  as  a  careful,  practical  guide  on  a  class  of  diseases,  which  form  so  large  and 
important  a  portion  of  the  duties  of  the  physician,  and  for  which  the  author's  position  has 
given  him  almost  unequalled  opportunities  for  observation  and  experience. 

We  can  do  very  little  to  add  to  the  favorable  re-  |  with  great  care  and  thoroughness.  The  chapters  on 
ception  which  has  already  been  given  by  the  medi-  i  constipation  and  intestinal  ubstruction  are  of  high 
cal  press  of  the  world  to  this  well  known  treatise  I  value,  and  are  worth  many  times  the  cost  of  the 
We  commend  to  all  practitioners  a  carefal  perusal  I  book,  which,  altogether,  is  a  most  excellent  one. — 
of  Dr.  Habershon's  wirk.  More  especially ,  we  draw  |  St.  Louis  Ulin.  Record,  June,  1S79. 

This  valuable  treatise  on  diseases  of  the  stomach 
and  alidonen  has  been  out  of  print  for  several  years, 
and  is  therefore  not  so  well  known  to  the  professioa 
as  it  deserves  to  be.     It  will  be  found  a  cyclopjedia 
of  information,  systematically  arranged,  on  all  dis- 
eases of  the  alimentiry  tract,  from  tlie  mouth  to  the 
rectum.     A  fair  proportion  of  each  chapter  is  devot- 
ed to  symptoms,  pathology,  and  therapeutics.    The 
I  pre.-^ent  edition  is  fuller  than  former  ones  in  many 
I  particulars,  and  has  been   thoroughly  revised  and 
!  amended  by  the  author.    Several  new  chapters  have 
!  been  added",  bringing  the  woi-k  fully  up  to  the  times, 
1  and  making  it  a  volume  of  interest  to  the  practitioner 
j  in  every  field  of  medicine  and  surgery.     Perverted 
I  nutrition  is  in  some  form  associated  with  all  diseases 
we  have  to  combat,  and  we  need  all  the  light  that 


attention  to  the  number  of  intestinal  diseases  re- 
corded in  its  pages,  cases  of  extreme  interest  clini- 
callyand  pathologically.  Thi^carefnl  record  shows 
that  the  work  is  no  compilation  bnt  a  careful  exposi- 
tion of  the  author's  personal  experience.  —  Canadian 
Med.  and  Surg.  Journ.,  May,  1S79. 

As  a  work  of  reference,  as  well  as  daily  study,  no 
work  yet  emanating  from  the  raedcal  press  is 
■worthy  of  more  careful  consideration  by  the  general 
practitioner  than  the  above.  With  the  careful  re- 
vision given  this  edition.  Dr.  Habershon's  work 
will  sti  1  remain  at  the  head  of  the  list,  and  con 
tinue  to  be  regirded  as  one  of  the  best  treatises  on 
abdominal  diseases  extant  — South.  Practitioner, 
June,  1879. 

There  have  been  many  laborers  in  this  depart- 
ment of  special  pathology,  and  among  thetn  no  one  '  can  be  obtained  on  a  subject  so  broad  and  general, 
has  done  better  service  than  Dr.  Habershon.  The  j  Dr  Habershon's  work  is  one  that  every  practitioner 
first  pditions  were  exhausted  long  since,  and  the  !  should  read  and  study  for  himself. — X  T.  Med. 
anthor  has  revised  the  one  now  under  consideration  i  Journ.,  April,  1879. 


JpOTHERGlLL  [J.  MILNER),M.D.  Ediv.,  M.R.C.P.  Land., 

J^  Asst.  Phys.  to  the  West  Lond   Hosp.  :  As.tt.  Ph ;/.■<.  to  the  City  of  Lond.  Hosp. ,  etc. 

THE  PRACTITIONER'S  HANDBOOK  OF  TREATMENT;  Or,  the 

Principles  of  Therapeutics.     In  one  very  neat  octavo  volume  of  about  550  pages  :  cloth, 

S4  00.  {Now  Ready.) 
Ourfriend.i  will  find  this  a  very  readable  book;  and  ^  he  knew  how  sngucstive  and  helpful  it  would  be  to 
thatitshcds  light  upon  every  theme  it  louchi-s, causing  !  him.— iJl.  Louis  Med:  and  Surg.  Journ  ,  April,  1877. 
t^e  practitioner  to  feel  more  certain  of  bi.s  diagnosis  in  We  heartily  commend  his  book  to  themedical  student 
difficult  cases.  We  confidently  comnii-nd  the  work  to  as  an  honest  and  iuteiligent  guide  through  the  mazes  of 
onr  readers  ns  one  worthy  of  careful  perusal.  It  lifihis  therapeutics,  and  assure  the  practitioner  wlio  has  grown 
the  way  over  obscure  and  difficult  passes  in  medical  ^^^y  j„  ^|,g  iiarne.ss  that  he  will  derive  pleasure  and  in- 
practice.  The  chapter  on  the  circuliitioii  of  the  blood  struction  from  its  perusal  Valuable  suggestions  and 
is  the  most  exhaustive  and  instructive  to  be  found.  It  ,„ati-rial  for  thought  abound  throughout.- iJ<wwn  JM/. 
is  a  book  every  practitioner  needs,  and  would  have,  if  ,  „„^  f-^^g  Journal,  Mar.  8,  1877. 

T>T  THE  SAME  AUTHOR.  ' 

THK  ANTAGONISM  OF  THER.VPEUTIC  AGENTS,  AND  WHAT 

IT  TEACHES.    Being  the  Fothergilli m  Prize  Essay  for  1878.    In  one  neat  volume,  royal 
12mo.  of  156  pages;  cloth,  $1  00.      {Just  Ready.) 


Henry  C.  Lea's  Publications — (Diseases  of  the  Skin,  &c.).         IV 
r>EYNOLDF^  [J.  KflSSELL).  M.D., 

-*-^        Pro/.  1)/ the  Principles  and  Prdct  ice  of  Medicine,  in  Univ.  College,  London. 

A  SYSTKM  OF  MRDICINE.  with  Notkr  and  Additions  by  TFfny  IIartr- 

HOKNK,  M.D.,  Inte  Professor  of  Hygiene  in  tlie  Univei'sity  of  Pennn.  In  three  Inrge  and 
Immlsoine  octfivo  volunies,  condiining  about  .'!000  closely  printed  double  eoluuincd  pages, 
with  numerous  illustrations.      (In.  PiefS  ) 

Reynolds's  Svstkm  of  Mkdicine,  recently  completed,  has  acquired,  since  the  first  appearance 
of  the  first  volume,  the  well  deserved  reputation  of  being  the  work  in  which  modern  British 
medicine  is  presented  in  its  fullest  and  most  practical  form.  This  could  scarce  be  otherwise  in 
view  of  the  fact  that  it  is  the  result  of  the  collaboration  of  the  leadii^  minds  of  the  profession, 
each  subject  being  treated  by  some  gentleman  who  is  regarded  as  its  highest  authority — as  for 
instance,  Diseases  of  the  Bladder  bj^  Sir  Henry  Thomi'Son,  Malpositions  of  the  Uterus  by 
Gkailv  Hewitt,  Insanity  by  Henijv  M.\udslbv,  Consumption  by  J.  IIughe.s  Bennet,  Dis- 
eases of  the  Spine  by  CuAULES  Bl.vnd  Radcufpe,  Pericarditis  byFiiANCis  Sib.son,  Alcoholism 
by  FuANcis  E.  Anstie,  Renal  Affections  by  William  Roberts,  Asthma  by  Hyde  Salter, 
Cerebral  Affections  by  t£  Charlton  Bastian,  Gout  and  Rheumatism  by  Alkiied  Baring  Gar- 
iiDD,  Constitutional  Syphilis  by  Jonathan  Hutchinson,  Diseases  of  tlie  Stomach  by  Wilson 
bo'X,  Diseases  of -the  Skin  by  Bai,manno  Squire,  Affections  of  the  Larynx  by  Morell  Mac- 
FENZiE,  Diseases  of  the  Rectum  by  Blizard  Curling,  Diabetes  by  Lauder  Bkunton,  Intes- 
tinal Diseases  by  John  Syer  Bri.stowe,  Catalepsy  and  Somnambulism  by  Thomas  King  CnAM- 
BERS,  Apople.xy  by  J.  Hughlings  Jackson,  Angina  Pectoris  by  Professor  Gairdner,  Emphy- 
sema of  the  Lungs  by  Sir  William  Jenner.  etc.  etc.  All  the  leading  schools  in  Great  Britain 
have  contributed  their  best  men  in  generous  rivalry,  to  build  up  this  monument  of  medical  sci- 
ence. St.  Bartholomew's,  Guy's,  St  Thomns's,  Universitj' College,  St  Mary's  in  London,  while 
the  Edinburgh,  Glasgow,  and  Manchester  schools  are  equally  well  represented,  the  Army  Medical 
School  at  Netley,  the  military  and  naval  services,  and  the  public  health  boards.  That  a  work 
conceived  in  such  a  spirit,  and  carried  out  under  such  auspices  should  prove  an  indispensable 
treasury  of  facts  and  experience,  suited  to  the  daily  wants  of  the  practitioner,  was  inevitable,  and 
the  success  which  it  has  enjoyed  in  England,  and  the  reputation  which  it  has  acquired  on  this 
side  of  the  Atlantic,  have  sealed  it  with  the  approbation  of  the  two  pre-eminently  practical  nations. 

Its  largs  size  and  high  price  having  kept  it  beyond  the  reach  of  many  practitioners  in  this 
country  who  desire  to  possess  it,  a  demand  has  arisen  for  an  edition  at  a  price  which  shall  ren- 
der it  accessible  to  all.  To  meet  this  demand  the  present  edition  has  been  undertaken.  The 
five  volumes  and  five  thousand  pages  of  the  original  will,  by  the  use  of  a  smaller  type  and  double 
columns,  be  compres?ed  into  three  volumes  of  about  three  thousand  pages,  clearly  and  hand- 
somel)'  printed,  and  offered  at  a  price  which  will  render  it  one  of  the  cheapest  works  ever  pre- 
sented to  the  American  profession. 

But  not  only  will  the  American  edition  be  more  convenient  and  lower  priced  than  the  English; 
it  will  also  be  better  and  more  complete.  Some  years  having  elapsed  since  the  appearance  of  a 
portion  of  the  work,  additions  will  be  required  to  bring  up  the  subjects  to  the  existing  condition 
of  science.  Some  diseases,  also,  which  are  comparatively  unimportant  in  England,  require  more 
elaborate  treatment  to  adapt  the  articles  devoted  to  them  to  the  wants  of  the  American  physi- 
cian ;  and  there  are  points  on  which  the  received  practice  in  this  country  differs  from  that 
adopted  abroad.  The  supplying  of  these  deficiencies  has  been  undertaken  by  Henry  Hakts- 
HORNE,  M.D.,  late  Professor  of  Hygiene  in  the  University  of  Pennsylvania,  who  will  endeavor 
to  render  the  work  fully  up  to  the  day,  and  as  useful  to  the  American  physician  as  it  has  proved 
to  be  to  his  English  brethren.  The  number  of  illustrations  will  also  be  largely  increased,  and 
no  effort  will  be  spared  to  render  the  typographical  execution  unexceptionable  in  every  respect. 
The  preparation  of  the  work  is  now  proceeding  as  rapidly  as  is  compatible  with  its  careful  exe- 
cution, and  its  appearance  may  be  expected  at  an  early  day. 


pox  [TILBURY),  M.D.,F.R.C.P.,and  T.  C.  FOX,  B.A.,  M.R.G.S., 

Physician  to  the  Department  for  Skin  Diseasefi,  Vnivfrsity  College  Honpitnl. 

EPITOME  OF  SKIN  DISEASES.     WITH  FORMULAE.     For  Stu- 
dents AND  Practitioners.    Second  edition, thoroughly  revised  and  greatly  enlarged.  In 
one  very  handsome  12mo.  volume  of  216  pages.     Cloth,  SI  38.      (Jitst  Ready.) 
The  names  of  the  anihors  are  quite  suffi?ieat  to  I  exceeds  in  size,  and  purp.isses  in  use,  its  predeces- 
command    this   book,   Dr    Tilljaiy  Fox   being   well  ;  sor.     The  worlc  is  ceitainly  a  valuable  addition  to 
knowu   as  occupying  a  place  in' the  frout  ranli  of  i  the  '•  haody  volume"  department  of  medical  litera- 
dermatologists  of  the  da.y.— Canadian  Jouriial  of  j  tare. — The  Med.  Bulletra,  May,  lb7S 
Med.  Sci.,  May,  1S7S.  For  stadeols  a  better  book  was  never  devised. — 

The  present  edition  of  the  Epitome  considerably  :  Cincinnati  Lancet  and  GUnie,  May,  1S7.9. 


'^ILSON  { ERASE  US),  F.R.  S. 

THE  STUDENT'S  BOOK  OF  CUTANEOUS  MEDICINE  and  D is- 

BASES  OF  THE  SKIN.    In  One  very  handsome  royal  i2mo.  volume.    $3  50. 
TJILLIER  {THOMAS),  M.D., 

Physician  to  the  Skin  Department  of  Univer.iity  College  Hospital,  etc. 

HAND-BOOK  OF  SKIN  DISEASES,  for  Students  and  Practitioners. 

Second  Am.  Ed.     In  one  royal  12mo.  vol.  of  358  pp.    With  Illustrationf      Cloth, $225. 

It   is  a   concise,  plain,  practical  treatise  on    the  I  dents    aid    practitioners.  —  Chicago    Medical  Ex- 

var  ous  diseases   of    the  skin  ;  just   such    a  work,  ^  aminer,   M»)    1865. 

indeed,  as  was  much  needed,  both  by  medical  stu- 


18 


Henry  C.  Lea's  Publications — {Practice  of  Medicine). 


L^INLAYSON  [JA3IES),  M.D., 

Physician  avd  Lecturer  on  Clinical  Medi-^ine  in  th".  Glasgoio  Western  Infirmary,  etc. 

CLIXICAL    DIAGNOSIS  ;    A    Handbook    for    Students    and    Prac- 
titioners of  Medicine.     In  one  handsome  ]2mo.  volume,  of  546  pages,  witli  85  illustra- 
tions.    Cloth,  S2  6.3.      {Jmt  Ready.) 
The  concurrence  of  gentlemen  specially  familiar  with  the  several  subjects  being  requisite  to 
the  satisfnctory  development  of  a  plan   so  extensive,  Dr.  Finlayson  hns  secured  the  co-operation 
of  Prof.  Gairdner,  who  has  contributed  the  chapter  on  the  Physiognomy  of  Disease  ;   Prof.  Wm. 
Stephenson   that  on  Disorders  of  the   Female   Organs;   Dr.  Alex.  Robertson  that  on  Insanity; 
Prof.  Samson   Gemmell  tljose  on  the  Sphygmograph  and  Physical  Diagnosis;   and  Dr.  Joseph 
Coates  those  on  the  Fauces,  Larynx,  and  Nares,  and  on  the  method  of  ^t\-ioxux\T\g  post-mortem 
examinations.     Other  chapters  have  enjoyed  the  advantage  of  revision  by  gentlemen  specially 
versed  in  their  several   subjects;    and  the  volume  is  presented  as  thoroughl}'  on  a  level  with 
the  most  advanced  condition  of  knowledge  in  a  department  which  has  made  such  rapid  strides 
of  advancement  within  the  last  few  years. 


The  book  is  an  excelleat  one,  clear,  concise,  conve- 
nient, practical.  It  is  replete  with  the  very  know- 
ledge the  student  needs  when  he  quits  the  lecture- 
room  and  the  laboratory  for  the  ward  and  sick-room, 
and  does  Bot  lack  in  information  that  will  meet  the 
wants  of  experienced  and  older  men. — Phila.  Med. 
Times,  Jan.  4.  1S79. 

The  aim  of  he  author  is  to  teach  a  student  and 
practitioner  how  to  examine  a  case  so  as  to  m&  "all 
his  knowledge"  in  arriving  at  a  diagnosis.  All  the 
various  symptoms  of  the  several  systems  are  grouped 
together  in  such  a  manner  as  to  mike  their  relations 
to  a  final  diagnosis  clear  and  easy  of  apprehension. 
This  work  has  been  done  by  men  of  large  experience 
and  trained  observation,  who  have  been  long  recog- 
nized as  authorities  upon  the  subj.'Cis  which  they 
treat.  There  is  a  profusion  of  illustrations  to  illus- 
trate subjects  under  discussion.  The  application  of 
electricity,  and  instruments  of  precision  in  diagnosis, 
i.s  fully  discussed.  This  book  i.s  all  good.  We  com- 
mend it  to  all  students  and  practitioners  of  medicine 
as  a  work  worthy  of  a  place  iu  their  libraries. — Ohio 
Med.  Recorder.  Dec.  1S7S. 


This  is  one  of  the  really  useful  books.  It  is  attrac- 
tive from  pr.-face  to  the  final  page,  and  ought  to  be 
given  a  place  on  every  office  table,  because  it  contains 
in  a  coiideuseil  form  all  that  is  valuable  in  semeiology 
and  diagnostics  to  be  found  in  bulkier  volnm>^s,  and 
becau-e  in  its  arrang-jment  and  complete  index,  it  is 
unusually  convenient  for  quick  reference  in  any 
emergency  that  may  come  upon  the  busy  practitioner. 
—  iV.  C.  Med.  Jourk.,  Jan.  1S79. 

This  is  a  most  important  work  for  students,  and 
one  that  is  d.stined  to  become  rapidly  popular.  It 
is  composed  of  contributions  from  various  eminent 
sources  bearing  upon  this  subject.  The  real  secret 
of  successful  practice  is  the  accurate  diagnosis  of 
disease.  This  manual  teaches  the  student  to  arrange 
his  investigation  in  such  system  as  to  enable  him, 
with  pract'ce,  to  acquire  this  very  desirable  faculty. 
The  division  of  the  subject,  as  in  this  work,  among 
the  highest  authori'ies  living,  is  a  good  idea,  and 
gives  us  in  one  compact  form  a  series  of  monographs 
written  by  masters. — Nashville  Journal  of  Iftd. 
and  Surg.,  Jan.  IS7.9. 


TJAMILTOS  {ALLAN  McLANE),  M.D., 


Attending  Pky.ncian  at  the  Hos2yitalforE2)ilepties  and  Paralytics,  BlackioelV s  Island,  N.  Y., 
OMd  at  the  Oat- Patients''  Department  of  the  New  Y'lrk  Huspitol. 

NERVOUS  DISEASES;  THEIR  DESCRIPTION  AND  TREATMENT. 

In  one  handsome  octavo  volume  of  512  pages,  with  53  illus. ;  cloth,  $3  50.  (Just  Ready.) 
This  is  unquestionably  the  best  and  most  com  connected  with  the  nerrous  system.  We  have  no 
plete  te.xt-book  of  nervous  diseases  that  has  yet  ap-  hesitation  in  saying  that  reliance  may  be  placed  on 
peared,  and  were  internal iooal  jealousy  in  scieniifle  !  Dr.  Hamilton's  conscientious  performance  of  his  selr- 
alfairs  at  all  possible,  we  might  be  excused  f  ir  a  j  assij;ned  task,  on  his  soundness  of  judgment,  and 
feeling  of  chagrin  that  it  should  be  of  American  |  freedom  from  empiricism. — Edinburgh  Med.  Joiirn., 
parentage.    This  work,  however,  has  been  performed     Oct.  1S7S. 

in  Xew  York,  and  has  been  so  well  performed  that  I  ^j.^^  ^  ^erv  careful  examination  of  the  whole 
no  room  is  left  for  anything  bat  commeadati..u.  '  -n-ork,  we  cat  fu^tlv  sa  v  that  the  author  has  not  only 
With  great  skill.  Dr.  Hamilton  has  presented  :o  his  ;  elearlv  and  fnllv  tfeated  of  diagnosis  and  treatment, 
readers  a  succinct  and  lucid  survey  ot  all  that  is  ^^^  ,j„i-,^..  ,^,,;t  ^^,.|j,  ^f  this  class,  it  is  verv  corn- 
known  ot  the  pathology  of  the  nervous  system,  ,  prehensive  in  regard  to  etiologv,  and  expos'es  the 
viewed  in  the  light  of  the  most  recent  researche-^  :  pathology  of  nervonsdiseases  iu  the  light  of  the  very 
From  the  preliminary  description  of  the  methods  oi;  i  ,.^g..t  experiments  md  discoveries.     The  dra 


examination  and  study,  and  of  the  instrnmeuts  of 
precision  employed  in  the  investigation  of  nervous 
diseases,  up  till  the  final  collection  of  formula),  tke 
book  is  eminently  practical. — Brain,  London,  Oct. 
1S7S. 

The  author  tells  us  in  his  preface  that  it  has  been 
his  object  to  produce  a  concise,  praciical  book,  and 
we  think  he  has  been  successful,  considering  the  ex- 
tent of  the  subject  which  lie  has  unilertaUen.  In 
fact,  it  is  more  extensive  than  liie  title  properly  or 


■awiugs 

are  excellent  and  well  selected.  After  this  careful 
revision,  we  can  heartily  recommend  this  work  to 
students  and  general  practitioners  in  particular  as 
beiug  a  full  expo-ition  of  aiseases  of  the  nervoas  sys- 
tem, their  pathnlugv  and  treatment,  to  date.  — jV.  Y. 
Mt-A.    Record,  Aug.  8,  ISTS. 

.\3  Stated  in  the  preface,  the  author's  object  has 
been  to  write  a  concise  and  practical  book,  for 
which  there  is  certainly  a  place,  and  we  think  he 
has  sucoreded   admirably  in   fnlfilliug   his   object. 


accurately  indicates,  embracing- besides   what  are  i  The  u^ual  plan  is  adopted   in  tie  classification   of 


usually  regarded  as  nervous  diseases — inflammatory 
affections,  both  acute  and  chronic,  bemorrhagos  and 
tumors  of  the  cerebrum  and  cerebellum,  medulla 
oblongata,  sjiinal  cord  and  nerves,  with  llircpinbosis 
and  embolism  of  the  arteries,  sinuses,  and  veins. 
The  reader  may  therefore  expect  information,  more 
or  less  full  and  satisfactory,  on  almost  every  point 


the  d  nVreut  disease^,  the  book  not  being  greatly 
unlike  Hammond's  in  this  respect,  although  it  is 
very  noticeable  lliroughout  that  the  author's  opin- 
ions vary  widely  from  those  of  l)r  Hammond. — Am. 
Siip/f.  O'istet.  Juurn.  Great  Britain  and  Ireland, 
July,  1S7S. 


m^ 


QHARCOT  [J. 

Professor  to  the  Faculty  of  Med.  PaH.i^  Phys.  to  La.  Salpffriire,  etc. 

LECTURES  ON  DISEASES  OF  THE  NERVOUS  SYSTE:M.    Trans- 

lated  from  the  Second  Edition  by  (jkoiigk  Siokhson,  M.D  ,  M  Ch.,  Lecturer  on  Biology, 
etc.,  Cath.  Univ.  of  Ireland.  With  illu.strations  (Putjlishing  in  the  Medical  Neiis  and 
Library,  commenoing  with  the  July  No.  187S      See  ptige  2  ) 


Henry  C.  Lea's  Publications — [Diseases  of  the  Chesty  &€.). 


19 


JjgROWN  [LENNOX),  F.R.G.S.  Ed., 

Senior  Surgeon  toihe.  Central  London  Throat  find  Ear  Honpitat,  etc., 

THE  THROAT   AND  ITS  DISEASKS.     With  one  liuiKliod  Typical 

Illustrations  in  ciilors,  and  fifty  wood  engrnvings,  designed  nnd  executed  by  tlie  author. 
In  one  very  hanUome  imperial  octavo  volume  of  -'JSlpages  ;  cloth,  $5  00.  (Now  Reciily  ) 
The  Huthor's  rare  arti.-;tic  skill  has  been  utilized  \  are  uuusiinUy  accurate.     In  coiicUisloii,  wo  reooni- 


in  tlie  vroductiou  of  one  In  udred  lieaiitiful  iliustia- 
lioiis  ill  colors,  ihe  very  he-^t  of  the  kind  we  have 
SfSQ.aud  whicli  liave  be>'n  ilistriliuied  iu  len  plates. 
Fifty  wiii.d  engraviogs,  designed  and  executed  by 
the  autiior,  appear  in  tlio  body  of  the  work — these 


uieud  lliis  lieaiitifiil  volume  as  an  accejitable  ad'li- 
tion  to  the  library  of  those  engaged  in  the  treatment 
of  diseaaes  of  the  throat. — X.  Y.  Med.  Jiecwd,  Nov. 

9,  is;s. 


JFALKR  (CARL),  M.D., 

-^  Lecturer  on  Laryngoiicopy  at  the  Univ.  of  Penna  ,   Chief  of  the  Throat  Dispensary  at  the 

l/niv.  Hospital,  Phila.,  etc. 

HANDBOOK  OF  DIAGNOSIS  AND  TREATMENT  OF  DISEASES  OF 

THE    THROAT    AND    NAS  \L   CAVITIES.      In   one  handsome  royal  12mo.  volume, 
of  151)  pages,  with  35  illustrations;  cloth,  §1.      (Just  Ready.) 


pLINT  (AUSTIN),  M.D., 

Pr  feasor  of  the  Principles  and  Practice  of  Medicine  in  Bellevite  Hospital  Med.  College,  N.  T. 

PHTHISIS:  ITS  MORBID  ANATOMY,  ETIOLOGY.  SYMI'TOM- 

ATIC  EVENTS  AND    COMPLICATIONS,  FATALITY  AND  PROGNOSIS,  TREAT- 
MENT, AND  PHYSICAL  DIAGNOSIS;   in  a  series  of  Clinical  Studies.     By  Austin 
Flint,  M.D.  ,  Prof,  of  the  Principles  and  Practice  of  Medicine  in  Bellevue  Hospital  Med. 
College,  New  York.     In  one  handsome  octavo  volume:  $3  60.      {Lately  Issued.) 
This  book  contains  an  analy.sis.  in  the  aullior"s  lucid  I  mend  the  book  to  the  perusul  of  all  interested  in  the 

Ftyle,  of  the  notes  which  lie  has  made  in  several  hun-     study  of  lliis  disease. — Boston  Med.  and  Surg.  Journal, 

dred  case.s  in  hospital  and  private  practice.     We  com-  |  Feb.  10.  1S76. 


OT  THE  SAME   AUTHOR. 

A  MANUAL  OF  PERCUSSION  AND  AUSCULTATION;   of  the 

Physical  Diagnosis  of  Diseases  of  the  Lungs  and  Heart,  and  of  Thoracic  Aneurism.     In 
one  handsome  royal  12mo.  volume:  cloth,  $1  75.      (Just  Issued.) 


B 


<Y  THE  SAME  AUTHOR. 

A  PRACTICAL  TREATISE  ON  THE  DIAGNOSIS,  PATHOLOGY, 

AND  TREATMENT  OF  DISEASES  OF  THE   HEART.     Second  revised  and  enlarged 

edition.     In  one  octavo  volume  of  550  pages,  with  a  plate,  cloth,  $4. 

Dr.  Flint  chose  a  difficult  subject  for  his  research  e-,  ;  anu  clearest  practical  treatise  on  those  subjects,  and 

and  has  shown  remarkable  powers  of  observation  ,  jhould  be  in  the  hands  of  all  practitioners  and  stu- 

aad  reflection,  as  well  as  great  industry,  in  his  treat- ,  ients    It  is  a  credit  to  American  medical  literature. 

iuent  of  it.    His  book  musi  be  considered  the  fullest  ,  —Amer.  Journ.  of  the  Med.  Sciences,  July,  1S60. 

■D  Y  THE  SA  ME  A  UTHOR . 

A  PRACTICAL  TREATISE  ON  THE  PHYSICAL  EXPLORA- 
TION OF  THE  CHEST  AND  THE  DIAGNOSIS  OF  DISEASES  AFFECTING  THE 
RESPIRATORY  ORGANS.  Second  and  revised  edition.  In  one  handsome  octavo  volume 
of  595  pages,  cloth,  $4  50. 


WII.LIAMSS  PULMONARY  CONSUMPTION;  its 
Nature,  Varieties,  and  Treatment.  With  an  An- 
alysis of  One  Thousand  Cases  to  exemplify  its 
duration.  In  one  neat  octavo  volume  of  about 
H50  pages  ;  cloth,  $2  .50. 

SLADE  ON  DIFHTHERIA;  its  Nature  and  Treat- 
ment, with  an  account  of  the  History  of  its  Pre- 
valence in  vnriouB  Countries.  Second  and  revised 
edition.  In  one  neat  roval  12mo.  volume,  cloth, 
$1  2.5. 

WALSHE  ON  THE  DISEASES  OF  THE  HE-^^RT  AMD 
GREAT  VESSELS.  Third  Arnorican  Edition.  In 
1  vol.  Svo.,  420  pp.,  cloth,  $3  00. 

LECTURES  ON  THE  DISEASES  UF  THE  STOMACH. 
With  an  Introduction  on  its  .\natomy  and  Physio- 
logy. By  Wii.i.iAM  Bri.nton,  M.D.,  F.R.S  From 
the  second  and  enlarged  Londonedition .  With  il- 
lustrations on  wood.  In  one  handsome  octavo 
volume  of  about  .'^OO  pages  :  cloth,  ^:i  2.0. 

LA  ROCHE  ON  PNEUMONIA.  1  vol.  8vo.,  cloth, 
of  .500  pages.    Price,  $3  00. 

LINCOLN'S  ELECTRO-THERAPEUTICS;  a  Concise 
Manual  of  Medical  Electricity.  In  one  very  neat 
royal  12mo.  volume,  cloth,  with  illustrations, 
§1   .50. 

CLINICAL  OBSERVATIONS  ON  FUNCTIONAL 
NERVOUS  DISORDERS  ByC.  H  a.vdfield  Jo.nrs, 
M.D.,  Physician  to  St.  Mary's  Hospital,  itc.  Sec 
end  American  Edition.  In  one  fan  ndsome  octavo 
volume  of  ;i4S  pages,  cloth,  $3  25. 


FULLER  ON  DISEASES  OF  THE  LUNGS  AND  AIR- 
PASSAGES.  Their  Pathology,  Physical  Diagno.si.~, 
Symptoin.s,  and  Treatment.  From  the  second  and 
revi.sed  English  edition.  In  one  handsome  ocatvo 
volume  of  about  500  pages  :  cloth,  $;^  50. 

CHAMBEKSS  .MANUAL  OF  DIET  AND  REGIMEN 
IX  IIE.^LTU  AND  SICKNESS.  In  one  handsjme 
octavo  volume.     Cloth,  .^2  75. 

CHAMBliRS'S  RESTORATIVEMEDICINE.  An  Har- 
veian  jVuaual  Oration.  With  Two  Sequels.  In 
one  very  handsome  vol.  small  12mo.,  cloih,  -SI  00. 

PAW'S  TREATiSE  ON  THE  FUNCTION  OP  DI- 
GESTION; its  Disorders  and  their  Treatment. 
From  the  second  London  edition.  In  one  hand- 
some volume,  small  octavo,  cloth,  ^2  00. 

PAVY'S  TREATISE  ON  FOOD  AND  DIETETICS. 
Physiologically  and  Therapeutically  Considered. 
In  one  handsome  octavo  volume  of  nearly  tiOO 
pages,  cloth,  ■'jil  75. 

S  'flTH  ON  CONSUMPTION  ;  ITS  EARLY  AND  RE- 
.M=;r>r  ABLE  STAGES.    1  vol.  Svo.,  pp.  2.54.   *2  2."^. 

BASHAM  ON  RENAL  DISEASES  :  a  Clinical  Guide 
to  their  Diagnosis  and  Treatment.  With  Illustra- 
tions   In  one  r2mo.  vol.  of  304  pages,  cloth,  !ji2  00. 

LECTURES  ON  THE  STUDY  OF  FEVER.  By  A. 
Hrn.^ioN,  M.D.,  M.R.I. A.,  Physician  to  the  Meath 
Hospital.     In  one  vol.  Svo.,  cloth,  ^2  50. 

A  TREATISE  ON  FEVER.  By  Robkkt  D.  Ltonp, 
K  C  C.  In  one  octavo  volume  of  362  pages,  cloth, 
$2  2o. 


20  Henry  C.  Lea's  Publications— ( Venereal  Diseases,  Sc). 

DUMSTEAD  [FREEMAN  J.),  M.D., 

■*-'         Professor  of  Venereal  Diseases  at  the  Qol.  of  Phys.  and  Surg..  New  York.  See. 

THE  PATHOLOGY  AND  TREATMENT  OF  VENEREAL  DIS- 

EASES.    Including  the  results  of  recent  investigations  upon  the  subject.    Fourth  edition, 
rerised  and  enlarged.     In  one  large  and  handsome  octavo  volume  of  over  700  pages. 

[Prepari?ig.) 

ffULLERIER  [A.),  and         JDUMSTEAD  {FREEMAN  J.), 

^        Surgeon  to  the  Hopitaldu  Midi.  -*-'       Professor  of  Venereal  Diseases  in  the  College  of 

Phy-noians  and  Surgeons.  N.  T. 

AN  ATLAS  OF  VENEREAL  DISEASES.  Translated  and  Edited  by 

Freeman  J.  Bumstead.  In  one  large  imperial  4to.  volume  of  328  pages,  double-columns, 
with  28  plates,  containing  about  150  figures,  beautifully  colored,  many  of  them  the  size  of 
life;  strongly  bound  in  cloth,  $17  00  ;  also,  in  five  parts,  stout  wrappers,  at  $3  per  part. 
Anticipating  a  very  large  sale  for  this  work,  it  is  ofiFered  at  the  very  low  price  of  Three  Dol- 
lars a  Part,  thus  placing  it  within  the  reach  of  all  who  are  interested  in  this  department  of 
practice.     Gentlemen  desiring  early  impressions  of  the  plates  would  do  well  to  order  it  without 
delay.     A  specimen  of  the  plates  and  text  sent  free  by  mail,  on  receipt  of  25  cents. 

We  wish  for  once  that  oar  province  was  not  re-  ;  of  illustration?  of  the  venereal  diseases-.  There  is, 
strict  d  to  methods  of  treatment,  that  we  might  say  I  however,  an  additional  interest  and  value  pof  sesped 
some.hing  of  the  exquisite  coloj-ed  plates  in  this  |  by  the  volumebefore  u?;  foritisan  American  reprint 
voixiia&.  -London  Practitioner,  il&y,lS(>9.  j  and  translation  of.M    Cullerier's  work,  with  inc!'- 

Other  writers  besides  M.  Cullerier  have  given  us  £  i  dental  remarks  by  one  of  the  most  eminent  Ameri- 
good  account  of  the  diseases  of  which  he  treats,  bui  <:«-a  syphilograDhers,  Mr.  Bumstead.-Brit  and  J?of . 
no  one  has  furnished  us  with  such  a  complete  seriei  \  ^edtoo-O/iir.  Review,  July,  IS69. 


TEE  [HENRY), 

-*-*        Prof,  of  Surgery  at  the  Royal  College  of  Surgeons  of  England,  etc. 

LECTURES  ON  SYPHILIS  AND  ON  SOME  FORMS  OF  LOCAL 

DISEASE  AFFECTING  PRINCIPALLY  THE  ORGANS  OF  GENERATION.    In  one 
handsome  octavo  volume:  cloth;  $2  25.      {Lately  Published.) 


H 


ILL  [BERKELEY], 

Sii-rgeon  to  the  Lock  Hospital,  London. 

ON  SYPHILIS  AND  LOCAL  CONTAGIOUS  DISORDERS.     In 

one  handsome  octavo  volume  ;  cloth,  $3  25. 


^EST  [CHARLES),  M.D., 

Physician  to  the  Hospita.lfor  Siek  ChiMren,  London,  &c . 

LECTURES  ON  THE  DISEASES  OF  INFANCY  AND    CHILP- 

HOOD.  Fifth  American  from  the  sixth  revised  and  enlarged  English  edition.  In  one  large 
and  handsome  octavo  volume  of  678  pages.  Cloth,  S4  50  ;  leather,  $5  60.  {Lately  Isftied  ) 
The  continued  demand  for  this  work  on  both  sides  of  the  Atlantic,  and  its  transl.ition  into 
German,  French,  Italian,  Danish,  Dutch,  and  Russian,  show  that  it  fills  satisfactorily  a  want 
extenuvely  felt  by  the  profession.  There  is  probably  no  man  living  who  can  speak  with  the 
authority  derived  from  a  more  extended  experience  than  Dr.  West,  and  his  work  now  presents 
the  results  of  learly  2000  recorded  cases,  and  600  post-mortem  examinations  selected  from 
among  nearly  40,000  ja.ies  which  have  passed  under  his  care.  In  the  preparation  of  the  pre- 
.«ent  edition  he  has  omitted  much  that  appeared  of  minor  importance,  in  order  to  find  room  for 
the  introduction  of  additional  caatter,  and  the  volume,  while  thoroughly  revised,  is  therefore 
not  increased   materiallj'  in  size. 

Of  all  the  English  writers  on  the  diseases  of  chil-  I  highest  living  authorities  in  the  difficult  department 
drdu,  there  is  no  one  so  entirely  satisfactory  to  us  |  of  medical  science  in  which  he    is   most  widely 
as  Dr.  West.     For  years  we  have  held  his  opinion  I  known.-  Boston  Med.  and  Surg.  Journal. 
as   judicial,  and  have  regarded  him  as  one  of  the  1 

TDF  TBE  SAME  AUTHOR.    { Lately  Issued.) 

ON  SOME  DISORDERS  OF  THE  NERVOUS  SYSTEM  IN  CHILD- 

HOOD;  being  the  Lumleian  Lectures   delivered   at  the  Royal  College  of  Physicians  of 
London,  in  March,  1871.     In  one  volume   small  12mo.,  cloth,  $1  00. 


^  T  THE  SA  VE  A  OTIIOR. 

LECTURES  ON  THE  DISEASES  OF  WOMEN.     Third  American, 

from  the  Third  London  edition.     In  one  neat  octavo  volume  of  about  550  pages,  clotl, 
$3  75;  leather,  $4  75. 

CONDIE'S  PRACTICAL  TREATISE  ON  THE  DIS-  |  SMITH'S  PRACTICAL  TREATISE  ON  THE  WAST- 
EA6ES  OF  CHILDREN.  Sixth  edition,  revised  ING  DISKASES  OF  INFANCY  AND  CH.  LDHOOD. 
and  augmented.  In  one  large  octwvo  volume  of!  Second  American,  from  the  second  revined  and 
nearly  f^'i)  closely-printed  pages,  cloth,  $.J  25;  enlaiged  Eojilisli  edition.  In  one  haadsome  ocla- 
leather,  $6  2-3.  to  voiame,  cloth,  $2  50. 


Henry  C.  Lea's  Publications — {Diseases  of  Children).  21 

SMITH  {J.  LEWIS),  M.D., 

^"^  Clinical  Pro/ejmor  of  Dine.nni>'i  of  Ohildri-n  in  the.  Be.llevue  HoDpitnl  Mid.  Onllege,  N  T. 

A  COMPLETE  PRACTICAL  TREATISE  ON  THE  DISEASES  OF 

CHILDREN.    Fourth  Edition,  revised  and  enlarged.     In  one  handsome  octavo  volume 
of  about  750  pages,  with  illustrations.     Cloth,  .$4  .00  ;   leather,  $.5  60.      {Now  Keridy.) 

The  very  marked  favor  with  which  this  work  has  been  received  wherever  the  English  lan- 
guage is  spoken,  has  stimulated  the  author,  in  the  pvei.aration  of  the  Fourth  Edition,  to  spare 
no  pains  in  the  endeavor  to  render  it  worthy  in  every  re.^pect  of  a  continuance  of  professional 
confidence.  Many  portions  of  the  volume  have  been  rewritten,  and  much  new  matter  intro- 
duced, but  by  an  earnest  effort  at  condensation,  the  size  of  the  work  has  not  been  materially 
ncreased. 

In  the  period  which  has  elapsed  since  the  third  '  This  excellent  work  in  co  well  known  that  an 
edition  of  the  work,  so  extensive  have  been  the  ad-  ex'ended  notice  at  Ibis  time  would  be  )*aperflnoui>. 
vauces  tlmt  whole  chapters  required  to  he  rewiittea,  ;  The  author  hts  taken  ad  van  la  gf  of  ihi-  deioaod  for 
and  hardly  a  page  could  pass  without  Slime  material  \  another  new  erit  on  to  revise  in  a  most  carelul 
correction  or  addition.  This  labor  has  occupied  the  manner  the  entire  book  ;  and  the  nnmeroaH  eorrec- 
writer  closely,  and  he  has  performed  it  cunscien-  j  tions  and  additions  evince  a  deteriiiinHiion  on  his 
tioasly,  so  that  the  book  may  he  considered  a  faith-  '  part  to  keep  fully  abreast  with  the  rapid  progress 
ful  portraiture  of  an  exceptionally  wide  clinical  that  Is  being  made  in  the  knowledge  and  treatment 
experience  in  infantile  diseases,  corrected  hy  a  care-  i  of  children's  diseases.  By  the  adoption  of  a  8('me- 
ful  study  of  the  recent  literature  of  the  subject. —  j  what  closer  type,  an  increase  in  nize  ol  only  thirty 
Med.  and  Surg.  Re.tjorter,  .\pril  5,  1879.  i  paees   has   been   necestitated  by  the   new  subject 

It  is  scarcely  necessary  for  us  to  say  the  work  be"  ^  matter  introduced.-J!o««o»  Med.  and  Surg.  Jour., 
fore  us  is  a  standard  work  upon  diseases  of  children,     May  -9.  lS/9. 

and  that  no  work  has  a  higher  stauding  than  it  upon  Probably  no  other  work  ever  published-  in  this 
those  aff^'ctions.  In  consequence  of  its  thorough  re-  '  country  upon  a  medical  subject  has  reached  such  a 
vision,  the  work  has  been  made  of  more  value  than  heighlh  of  populirity  as  has  this  well-known  trea- 
ever,  and  may  be  regarded  as  fully  abreast  of  the  tise.  As  a  text  and  reference-book  it  is  pre-enii- 
times.  We  cordially  commend  il  to  students  and  ,  nently  the  authority  upon  diseases  of  children.  It 
physicians.  There  is  no  better  work  in  the  language  |  stands  deservedly  higher  in  the  estimaiion  of  the 
on  diseases  of  children. — Cincinnati  Med.  News,  \  proftssion  than  any  other  work  upon  the  same  sub- 
March,  1S79.  ;  ject.— Nashville  Journ.  of  Med.  and  Surg.,  May, 

The  author  has  evidently  determined  that  it  shall  1S79. 
not  lose  ground  in  the  esteem  of  the  profession  for  I  The  author  of  this  work  has  acquired  an  immense 
want  of  the  latest  knowledge  on  that  important  experience  as  physician  to  three  of  the  large  char- 
department  of  meilicine.  He  has  accordingly  in-  ities  of  New  York  in  which  children  are  treated, 
corporated  in  the  present  edition  the  useful  and  These  asylums  afford  unsurpassed  opportunities  for 
practical  reiultsof  the  latest  study  and  experience,  observing  the  efftcts  of  different  plans  of  treatment, 
both  American  and  foreign,  especially  those  beating  and  the  lesults  as  embidied  in  this  volume  may  be 
on  therapeutics.  Altogether  the  book  has  been  j  accepted  with  faith,  and  should  be  in  the  possession 
greatly  improved,  while  it  has  not  been  greatly  i  of  all  practitioners  now,  in  vi^w  of  the  appnacbing 
increased  in  size.  —  New  York  Jiftc^ieai  /ournaZ,  i  season  when  the  diseases  of  children  always  increase. 
June,  1879.  1  —Nat.  Med.  Review,  April,  1S79. 


Jg WAYNE  {JOSEPH  GRIFFITHS),  31. D., 

Physicinn-Accoueheur  to  the  British  General  Ho.'ipifol,  &c. 

OBSTETRIC  APHORISMS  FOR  THE  USE  OF  STUDEXTS  COM- 
MENCING MIDWIFERY  PRACTICE      Second  American,  from  the  Fifth  and  Revised 
London  Edition,  with  Additions  by  E.  R.  Hutchins,  M.D.  With  Illustrations.   In  one 
neat  12rao.  volume.     Cloth,  $1  25.     (Lately  Isstted.) 
*^*  See  p.  4  of  this  Catalogue  for  the  terms  on  which  this  work  is  ofTered  as  a  premium  to 
subscribers  to  the  "  American  Journal  of  the  Medical  Sciences." 

CHURCHILL  ON  THE  PUERPERAL  FEVER  AND  j  .MEIGS  ON  THE  NATURE,  SIGNS,  AND  TREAT- 
OTHER  DISEASES  PECULIAKTO  WOMEN.  1vol.  !  MENT  OF  CHILDBED  FEVER.  1  vol.  Svo.,  pp. 
SvD.,  pp.  4.10,  cloth.     $2  oO.  '  -36-1.  cloth.     82  (0. 

DEWEEiS'R  TREATISE  ON  THE  DISEASES  OF  FE-    ASH  WELL'S  PRACTICAL  TREATISE  ON  THE  Oli- 
MALES.    With  illustrations.    Eleventh  Edition,  i      EASES  PECULIAR  TO  WOMEN.  Third  Americm, 
with  the  Author's  lastimprovements and  correc-  i      from  the  Third  andrevised  Londonedition.  1vol. 
tions.    In  one  octavo  volume  of  .036  pages,  with  i      8vo.,  pp.  .028,  cloth.    -$3  50. 
plates,  cloth.    $.3  00.  [ 

TJODGE  {HUGH  L.),  M.JD^, 

Emeritu.9  Pro/e.tf.nr  of  Ob.Hetrins,  &c.,  in  the  University  of  Pennsylvania. 

ON  DISEASES  PECULIAR  TO  WOMEN  ;  including  Displacements 

of  the  Uterus.     With  originalillustrations.    Second  edition,  revised  and  enlarged.     In 

one  beautifully  printed  octavo  volume  of  5.31  pages,  cloth,  $4  50. 

Professor  Hodge's  work  ts  truly  an  original  one  I  contribution  tothe  study  ofwomen'sdisease8,itisrf 

from  beginning  to  end,  consequently  no  one  can  pe-    great  value,  and  is  abundantly  able  to  stand  on  its 

raseits  pages  without  iearningsornething  new.  Af-a  I  own  merits. — N.  Y.  Mtdieal  Record,  Sept.  15,  ISfct. 

HURGHILL  {FLEETWOOD],  M.D.,  M.R.I.A. 
ON  THE  THEORY  AND  PRACTICE  OF  MIDWIFERY.    A  new 

American  from  the  fourth  revised  and  enlarged  London  edition.  With  notes  and  additioi  s 
by  D.  Francis  Condie,  MD.,  author  of  a  "  Practical  Treatise  on  the  Diseases  of  Chil- 
dren," &c.  With  one  hundred  and  ninety  four  illustrations.  In  one  very  handsome  octavo 
volume  of  nearly  700  large  pages.     Cloth.  $4  00  ;  leather,  $5  00. 

MONTGOMERY'S  EXPOSITION  OF  THE  SIGNS  RtGBY'S  SYSTEM  OF  MIDWIFERY.  With  notes 
AND  SYMPTOMS  OF  PREGNANCY.  With  two  and  Additional  Ulnstrations  Second  American 
exquisitecolored  plates,  and  numerons  wood  cuts.  ^'lUion.  One  volume  octavo,  cloth,  422  puges, 
In  1vol. 8vo.,ofn'early600pp., cloth, i3  75.  i      $2.30. 


C' 


22  Henry  C.  Lea's  Publications — (Diseases  of  Women). 

f  HO  MAS  {T.GAILLARD),M.D., 
Pro/es-for  of  Obstetrics,  &c.,  in  the  College  of  Physicians  and  Surgeons,  N.  T.,  &e 

A  PRACTICAL  TREATISE  ON  THE  DISEASES  OF  WOMEN.  Fourth 

edition,  enlarged  and  thoroughly  revised.  In  one  large  and  handsome  octavo  volume  of 

800  pages,  with  191  illustrations.     Cloth,  $5  00;  leather,  $6  00.     (Just  Issued.) 

The  author  has  taken  advantage  of  the  opportunity  afforded  by  the  call  for  another  edition  of 

this  work  to  render  it  worthy  a  continuance  of  the  very  remarkable  favor  with  which  it  has  been 

received.  Every  portion  has  been  subjected  to  a  conscientious  revision,  and  no  labor  has  been 

spared  to  make  it  a  complete  treatise  on  the  most  advanced  condition  of  its  important  subject. 

.A.  work  which  has  reached  a  fourtli  eilition.  and  is  classical  without  beingpedantic.fuU  in  the  details 
that.  too.  in  the  short  space  of  five  years,  has  achieved  of  anatomy  and  pathology,  without  ponderous 
a  reputation  which  places  it  almost  beyond  the  reach  translation  of  pages  of  Gevma,n  literature,  describes 
of  criticism,  and  the  favorable  opinions  which  we  have  ;  distinctly  the  details  and  difficalties  of  each  opera- 
a  ready  expressed  of  the  former  editions  seem  to  re-  :  tion,  without  wearying  and  useless  minutia,  and  is 
quire  that  we  should  do  little  more  than  announce  in  all  respects  a  work  worthy  of  confidence,  justify- 
this  new  issue.  We  cannot  refrain  from  saying  that,  ing  the  high  regard  in  which  its  distinguished  an- 
as a  practical  work,  this  is  second  to  none  in  the  Eng-  |  thor  is  held  by  the  profession. — Am.  Supplement, 
lish,  or.  indeed,  in  any  other  language.    The  arrange-  i  Ohstet.  Jonrn.,  Oct.  1S74:. 

ment  of  the  contents,  the  admirably  clear  manner  in  '      „     ,  ,„,  ,.   ,     .      ^,,      t^     ,      .  <.,-l 

which  the  subject  of  the  differential  diagnosis  of  ■„  P^'ofessorThomasfairly  took  the  Profession  of  the 
several  of  the  diseases  is  handled,  leave  nothing  to  be  United  btates  by  storm  when  his  book  first  made  its 
desired  by  the  practitioner  who  wants  a  thoroughly  appearance  early  in  1S6S.  Its  reception  was  simply 
clinical  work,  one  to  which  he  can  refer  in  difficuU  \  eathusiaslic,  notwithstanding  a  few  adverse  criti- 
cases  of  doubtful  dia-nosis  with  the  certainty  of  gain-  •  <=i-'^™s  f"'"™  '^^'^  transatlantic  brethren,  the  first  large 
ing  light  and  instruction.  Dr.  Thomas  is  a  man  with  a  edition  was  rapidly  exhausted,  and  in  six  months  a 
very  clear  he.-id  and  decided  views,  and  there  seems  to  second  one  was  issued,  and  in  two  years  a  third  one 
be  nothing  which  he  so  much  dislikes  as  hazy  notions  was  announced  and  published,  and  we  arenowpro- 
of  diagnosis  and  blind  routine  and  unreasonable  thera-  mised  the  fourth.  The  popularity  of  this  work  was 
peutics.  The  student  who  will  thoroughly  study  this,  not  ephemeral,  and  itssuccess  wasunprecedentedin 
b)Ok  and  test  its  principles  bv  clinical  observation,  will  '  the  annalsof  American  medical  literaiure.  Six  years 
certainly  not  be  guilty  ofthesefaults.— io?!doraia?ice<,  :  is  ^  i"°S  period  in  medical  scientific  research, -but 
Feb.  1.3,  IST.'i.  \  Thomas's  work  on  "  Diseases  of  Women"  is  still  the 

T,„,    1,      ,,  T.,.      3  ^      ,  1.  ,.     i  leading  native  production  of  the  United  States.  The 

Reluctantly  we  are  obliged  to  close  this  unsatis-  i  order,  the  matter,  the  absence  of  theoretical  disputa- 
T.  J  7"<=^"^  so  excellent  a  work,  and  in  conclu-  ^^eness,  the  fairness  of  statement,  and  the  elegance 
son  would  remark  that  as  a  teacher  ofgyn^cology.  of  diction,  preserved  throughout  the  entire  range  of 
l...thddac,icandchnical,Prof.Thomashascenainly  the  hook,  indicate  that  Pl-ofessor  Thomas  did  not 
it^h^    i  .  far  ahead  of  his  co7j/rer«.9  and  as  an    overestimate  his  powers  when  he  conceived  the  idea 

ftpAn.^!  certainly  has  met  with  unusual  and  mer-  .  ^^^  executed  the  work  of  producing  a  new  treatise 
ited  success.-^m.Vw^i.  of  Ohstetrics,  Aov.  1874.  |  ^pon  diseases  of  women.-PaoF.  PALLEX,in  Louia- 

This  volume  of  Prof.  Thomas  in  its  revised  form    mile  Med.  Journal,  Sept.  lS7i. 


J>ARNES  [ROBERT),  M.D.,  F.R.C.P., 

■'-'  Ohstetrie  Physician  to  St.  Thomas's  Ho.ypital,  &c. 

A  CLINICAL  EXPOSITION  OF  THE  MEDICAL  AND  SFRGI- 

CALDISEASES  OF  WOMEN.  Second  American,  from  the  Second  Enlarged  and  Revised 
English  Edition.  In  one  Handsome  octavo  volume,  of  784:  pages,  with  181  illustrations. 
Cloth,  .«4  50;  leather,  $5  50.      {Just  Ready.) 

The  call  for  a  new  edition  of  Dr.  Barnes's  work  on  the  Diseases  of  Females  has  encouraged 
the  author  to  make  it  even  more  worthy  of  the  favor  of  the  profession  than  before.  By  a  rear- 
rangement and  careful  pruning  space  has  been  found  for  a  new  chapter  on  the  Gyntecological 
Relations  of  the  Bladder  an  i  Bowel  Disorders,  without  increasing  the  size  of  the  book,  while 
many  new  illustrations  have  been  introiliiced  where  experience  has  shown  them  to  be  needed.  It 
is  therefore  hoped  that  the  volume  will  be  found  to  reflect  thoroughly  and  accurately  the  present 
condition  of  gynecological  science. 

Dr  Barnes  stands  at  the  head  of  his  profession  in  the  work  is  a  valuable  one,  and  should  be  lartrely 
the  old  country,  and  it  requires  but  scant  scrutiny  ,  consulted  by  tlie  profession. — Am.  St'pp  O'l-iletricid 
of  his  hook  to  show  that  it  has  been  sketched  by  a  Jotirn.  Gt.  Britain  and  Ireland,  Oct.  1S7S. 
rnnster.  It  is  plain,  practical  common  sense  ;  shows  j^  ^^  .  gynaecological  work  holds  a  higher  posi- 
^rJlvc'^^c'lff"  ,'^"'"'"*  ""n^  pedantic;  IS  emi-  i  ,ion,  havinf  become'  an  authority  every'where  in 
^!r..r^r^  to  inspire  e,.lmsiasm  without  in-  I  ji,^^,g,  of  women.  The  work  has  been  brought 
«r.1t,.H^Jw^r'\\^"'°''  °^'  "'  ''f'^"'!  ^\l^  fully  abreast  of  present  knowledge.  Everv  practi- 
vlr  nn=  onlf^'  '^  '"'T?  '"  ■  f  'f^'.'^Y'^  ^\^^%  tiouer  of  medicine  should  have  itS.pon  the  shelves 
rpTHL.'^rHwnr"'''t\  ""''''  '';':%  '"°=^  "/  of  his  library,  and  the  student  will  find  it  a  superior 
r.fh  nf  ?i;  much  to  smooth  the  rugged     text-book.-CTuci^naa'  Med.  News,  Oct.  1S7S. 

path  of  the  young  gyn.'ecologist  and  relieve  the  per-  i      _, 

plexity  of  the   man    of  mature  viAYs.  — Canadian  \      This  second  revised  edition,  of  course,  deserves  all 
Journ.  of  Med.  Science,  Nov.  1S7S.  '  '''«  commendation  given  to  us  predecessor,  with  the 

I  additional  one  that  it  apiiears  to  include  all  or  nearly 

We  pity  the  doctor  who,  having  any  consider- .  all  the  additions  to  our  knowledge  of  its  subject  that 
able  practice  in  diseases  of  women,  has  no  copy  of  ,  have  been  made  since  the  appearance  of  tlie  first  edi- 
I' Barnes"  for  daily  coiisultalion  and  inslructioa.  It  tion.  'J'he  American  references  are,  for  an  English 
is  at  once  a  book  of  great  learning,  research,  and  i  work,  especially  full  and  appreciative,  and  we  can 
individual  experience,  and  at  the  same  time  emi-  I  cordially  recommend  the  volume  to  .\merican  read- 
nently  practical.  That  it  has  been  appreciated  by  ers. — Journ.  of  Nervous  and  Mental  Disease,  Oct. 
the   profession,  both   in    Groat   Kritain   and  in  this    1878. 

!^"«i7'  I*  '*'"'»T"  ''/  1''®  f  ""n  ""^Vir  •■'^""■^'"S        This  second   edition   of  Dr.  Barnes's  great  work 
1S7S  "  fl'-6t--^"i-   Practitumer,   iNov.  j  gon,es  to  „s  c^nt-lining  many  additions  and  improve- 

j  ments  which  bring  it  up  to  dale  in  every  feature. 
Dr.  Barnes's  work  is  one  of  a  practical  character,  ;  The  excellences  of  the  work  are  too  well  known  to 
largely  illustrated  from  cisesin  hisown  experience,  '  reciuire  euumenition,  and  we  hazard  ihe  prophecy 
b-ii  by  no  meau.->  couliued  to  such,  as  will  be  learned  that  they  will  for  many  years  maintain  its  high  po- 
from  the  fact  that  he  quotes  from  no  lefs  than  628  sition  as  a  standard  textbook  and  guidebook  for 
medical  authors  in  numerous  countries.  Coming  i  students  and  practitioners.  —  N.  C.  Med.  Journ., 
from  such  an  author,  it  is  noJ  necessary  to  say  that  ,  Oct.  1878. 


IIf;.\iiY  C.  Lea's  PunLTCATioxs — (7);spa.srs  o/  Women). 


23 


TPM3IET  {THOMAS  ADDIS).  M.D. 

-*-*  Hurge.un  to  the  Wumfin'fi  lIo»pilnl,  Ano  York,  etr. 

THE  PRINCIPLES  AND  PRACTICE  OF  GYNAECOLOGY,  for  the 

use  of  Students  and  Pr.ictilioners  of  Medicine.  In  one  liirge  and  very  handsome  octavo 
volume  of  850  pages,  with  130  illustrations.  Cl.th,  $5;  leather,  $6.  (Just  Ready) 
Dr  Emmet  is  so  widely  known  ns  among  the  most  eminent  of  those  who  have  made  pynas- 
cologj-  a  peculiarly  American  science  that  the  profession  cannot  fail  to  welcome  a  work  in  which 
he  has  condensed  the  results  of  his  Ions;  and  e.vtensive  experience.  He  has  sought  to  consider 
the  whole  subject  of  the  diseases  peculiar  to  females  in  a  manner  which  will  adapt  the  volume, 
not  only  to  the  wan(s  of  the  st.udent  as  a  te.\t-book,  but  to  those  of  the  practitioner  as  an  aid  in 
the  emergencies  of  daily  practice.  A  special  feature  of  the  work  will  be  found  in  the  numerous 
condensed  tables,  which  convey  at  a  glance,  and  within  the  narrowest  compass,  the  conclusions 
to  be  drawn  from  the  many  thousand  cases  which  have  passed  under  the  care  of  the  author. 
With  trifling  exceptions,  the  illustrations  are  all  original,  and  the  volume  will  be  found  in  every 
point  of  typographical  execution  worthy  of  the  distinguished  position  which  is  confidently  anti- 
cipated for  it. 


It  may  be  said  that  he  has  bad  opportunities  for 
observatiou  and  expeiieace,  for  unfetiereu  and  un- 
restraiaed  exper mentation,  und  for  testing  the 
value  of  the  original  and  dazzling  operations  first 
proposed  and  performed  by  his  illastrioas  predccts- 
sors  before  relerred  to,  and  for  devising  new  opera- 
tions and  discovering  pathological  cause?  never 
before  suspected  or  described,  which  no  man  in  the 
profession  has  ever  befure  secured.  We  also  think 
that  the  reader<  of  this  work  will  agree  with  us, 
after  its  careful  perusal,  that  he  has  a  rare  capacity 
for  discriminating  acaly^i?,  and  generally  for  phi- 
losophical deduction  and  the  equally  important 
quality  of  patient,  honest,  continued  work.  For  the 
work  as  a  whole,  we  have  only  praise.  It  deserves 
and  will  receivf-  the  careful  study  of  all  who  desire 
to  keep  on  a  level  with  the  progreso  of  Gynaicology. 
It  embodies  a  larg.'r  amonut  of  carefally  analyzed 
personal  experience  in  a  unique  field  for  observa- 
tion than  any  volume  on  Diseases  of  Women  which 
has  yet  been  published.  Its  great  merit  coufiists  in 
this — coming  as  it  does  from  a  thoroughly  honest, 
competent,  and  able  specialist,  who  became  a  spe- 
cialist only  after  an  ixcellent  training  and  experi- 
ence as  a  general  hospital  phy^ician  and  surgeon. 
The  book  is  not  one  to  be  h.isti  ly  glanced  over,  but 
will  secure  the  critical  stuHy  of  Gycjecologiste.  Jfot 
only  its  style,  which  is  individual  and  somewhat 
peculiar,  but  the  new  fact.s  which  it  brings  out,  its 
original  suggestions,  its  nnioerous  and  important 
statistical  tables,  and.  in  some  instances,  its  unex- 
pected deductions,  w'll  Compel  attention,  and  will 
form  the  basis  for  a  great  deal  of  Gy nacoiogical 
studyand  literature  iii  the  future.  All  who  make 
themselves  familiar  with  the  contents  of  this  vol- 
ume, will  feel  a.ssured  that  Pr.  Emmet  has  well 
earned  and  well  deseived  the  reputation  which  he 
has  already  won,  as  one  of  tie  gi  e^t  Gynaecologists 
of  the  present  age. — The  Am.  Journ.  of  Obstetrics, 
April,  1S79. 

We  have  examined  this  book  with  something  more 
than  ordinary  care,  and  now  lay  it  aside  captivated 


by  our  impressions  of  it.  From  first  to  last,  each 
page  grows  in  interest,  and  ooe  is  struck  with  the 
practical  tone  of  all  that  is  said.  It  is  indeed  the 
gyntecological  work  for  the  practitioner.  Its  equal 
is  not  yet  published,  or  at  least  we  have  not  seen  it. 
We  cannot  send  'his  notice  forward  without  reiter- 
ating that,  in  our  estimation,  Emmet's  Principles 
and  Practice  of  Gynaecology  is  nndoublelly  the  best 
book  for  the  student,  as  well  as  the  general  practi- 
tioner, which  is  at  present  published. —  Va.  Med. 
Monthly,  May,  1S79. 

The  advent  of  this  important  work  has  for  some 
time  been  anxiously  expected  by  all  who  are  inter- 
ested in  the  subject  of  eynacology,  both  here  and 
abroad.  The  clinics  held  at  the  Woman's  Hospital, 
and  the  minor  writings  referred  to  have  acquired 
for  Dr.  Emmet  a  lepaiatiun  for  skill  as  an  operator, 
and  experience  in  the  special  b.auch  to  which  he 
has  exclusively  confined  his  attention,  which  i.s 
probably  unrivalled  by  any  one  on  this  continent. 
The  anticipations  which  have  been  awakened  re- 
garding the  character  of  this  extended  treatise,  are 
not  likely  to  be  disappointed,  if  one  may  judge  from 
the  very  cursory  review  we  have  made  of  its  con- 
tents.— NkVj  Remtdies,  May,  1S79. 

Few  have  had  the  rare  opportunities  of  Dr.  Em- 
met, and  none  have  better  improved  that  which  was 
at  their  disposal.  Sure  are  we  that  any  practi- 
tioner of  medicine,  specialist,  or  otherwise,  who  will 
read  carefully  this  volume,  will  find  that  he  pos- 
sesses a  c'earer  insight  into  a  thousand  problems 
that  have  hitherto  perplexed  him.  It  is  one  of  the 
best  original  works  on  the  diseases  of  women  pub- 
lished in  this  or  any  other  land.  We  heartily  com- 
mend it  to  the  careful  studv  of  every  medical  man. 
—Detvit  Lanctt.  Mity,  1S79. 

Weare  satisfied  thatwhoever  reads  thebook  care- 
fully will  agres  with  us  that  it  is  the  best  work  on 
gynsecology  that  has  ever  been  written.  This  is 
high  praise,  but  we  have  no  hesitation  in  giving  it. 
— St.  Louis  Otin.  Record,  M:iy,  1S79. 


flHADWICK  [.JA31ES  R.),  A.M.,  M.D. 

A  MANUAL  OF  THE   DISEASES  PECULIAR  TO  WOMEN.    In  one 

nent  volume,  royal  12mo  ,  with  illustrations.  (Preparing.) 
America  has  contributed  so  largely  to  the  advances  which  have  made  the  treatment  of  Dis. 
eases  of  Women  a  distinctive  department  of  medical  science,  that  the  student  will  naturally 
turn  to  American  Books  for  the  latest  and  most  trustworthy  instruction  on  the  subject  in  its 
most  modern  aspect.  Yet  there  has  thus  far  been  no  attempt  in  this  country  to  produce  a  handy 
manual,  presenting  in  a  condensed  and  convenient  form  the  information  requisite  for  the  learner 
or  for  the  general  practitioner.  This  want  it  has  been  the  effort  of  Dr.  Chadwick  to  supply,  and 
the  special  attention  which  he  has  devoted  to  the  subject  is  a  guarantee  of  the  value  of  his  labors. 
A  distinguishing  feature  of  the  work  will  be  a  number  of  diagrammatic  illustrations,  facilitating 
greatly  the  comprehension  of  the  text. 


lT;riNCKEL  (F.), 

f  '  Professor  and  Director  of  the  Gynacologieiil  Clinic  in  the  University  of  Rostock.  ' 

A  COMPLETE  TREATISE  ON  THE  PATHOLOGY  AND  TREAT- 
MENT OF  CHILDBED,  for  Students  and  Practitioners.  Translated,  with  the  consent 
of  the  author,  from  the  Second  German  Edition,  by  James  Rk.vd  Cu.vdwicic,  M  D.  In 
one  octavo  volume.     Cloth,  $t  00.     {Lately  Issued.) 


24 


Henry  C.  Lea's  Publications — (Midivifery). 


JpLAYFAIR  (  W.  S.),  M.D.,  F.R.C.P., 

Professor  of  Obstetric  Medicine  in  King's  College,  etc.  etc. 

A  TREATISE  ON  THE  SCIENCE  AND  PRACTICE  OF  MIDWIFERY. 

Second  American,  from  the  Second  and  Revised  English  Edition.     Edited,  with  Addi- 
tions, by  Robert  P.  Harris^,  M.D.     In  one  handsome  octavo  volume  of  639  pages,  with 
182  illustrations.     Cloth,  §4  00;   Leather,  $5.00.      (Just  Ready  ) 
In  reprinting  this  work  from  the  second  London  edition,  the  position  which  it  has  assumed 
in  this  country  as  an  authoritative  text-bools  seemed  to  call  for  such  additions  as  would  render 
it  more  completely  suited  to  the  wants  of  the  American  student.      A  careful  scrutiny  on  the  part 
of  the  editor  has  ?hown  that  but  little  was  required  for  this  purpose  ;  the  worli,  though  condensed, 
being  very  complete  and  accurate.     With  the  exception  of  numerous  short  foot-notes,  therefore, 
his  additions  have  been  confined  to  points  in  which  the  experience  and  practice  of  American 
obstetricians  differ  from  those  of  England,  and  to  one  or  two  matters  of  recent  interest.     These 
are  chiefly  the  Csesarean  Section  ;  the  varieties  of  forceps,  and  their  use  in  the  dorsal  decubitus; 
dystocia  from  tetanoid  uterine  constriction;   and  the  intra-venous  injection  of  milk,  as  a  substi- 
tute for  the  transfusion  of  blood. 


The  position  which  this  work  has  so  qa'ckly  taken 
in  this  country  as  an  antboriiative  text-book  renders 
any  extended  con^ideration  of  it^  flan  and  scope 
unnecessary.  Its  merits,  which  are  many,  have  al- 
ready foiiod  their  way  to  ihe  appreciation  of  students 
and  practitioners  alike  in  tl  e  leng'h  and  breadth  of 
the  land. — Am.  Stipp.  Ohdet.  Journ.  of  Gt.  Britain 
and  Ireland,  Oct.  1S7S. 

This  excellent  text-book  has  been  submitted  to  a 
thorough  and  careful  revision,  and  will  be  found 
fully  up  to  the  times  in  every  department.  The 
rotes  by  the  American  editor  enhance  the  valne  of 
the  work  for  the  American  student.  Those  on  the 
use  of  forceps  are  particaljrly  gjod,  and  constitute 
by  themselves  a  valuable  chapter. — JS'.  Y.  Mtd. 
Journ.,  Nov.  1S78. 

The  b^st  work  on  the  subject  ever  published  in  the 
English  language  It  is  written  in  a  clear,  pleasant 
style,  with 'ut  "that  verbosity  which  characterizes 
some  modern  and  highly  pretentious  works.  The  au- 
thoi-  is  quite  up  with  the  times,  both  in  practice  and 


theory.  It  is  the  best  text-book  we  have  for  students, 
and  sufficiently  full  of  detail  to  supply  all  the  wants 
of  the  practitioner.  We  would  gladly  see  it  in  the 
hands  of  all  who  practise  midwifery.  —  Canadian 
Journ.  of  Med.  Sci.,  2s  ov.  1S7S. 

Probably  this  is  the  very  best  and  most  useful 
manual  of  midwifery  now  available  to  the  profes- 
sion. Itiswritteniu  lucid,  scholarly  English,  which 
some  of  our  cis-Atlantic  writers  would  do  well  to 
imitate.  There  has  been  no  attempt  to  swell  the 
magnitude  of  the  work  by  fine  writing,  or  by  lengthy 
discussions  ofobf  cure  points  of  which  no  trustworthy 
solution  has  yet  been  reached  ;  on  the  contrary,  the 
tendency  is  throughout  obviously  towards  simplic- 
ity. The  chapter  upon  the  Mechanism  of  Labor 
(which  oug'it  to  be  the  crowning  chapter  in  a  trea- 
tise on  obstetrics)  is  remarkably  clear  and  good,  aud 
is  divested  of  those  features  which  in  almost  every 
other  work  we  know  lets  only  darkness  instead  of 
light  in  upon  the  subject.  —  M.  C.  Med.  Journ.,  Oct. 
187S. 


JDARNES  {FANCOURT),  M.D., 

-*--'  Physician  to  the  General  Lying-in  Hospital,  London. 

A  MANUAL  OF  MIDWIFERY  FOR  MIDWIYES. 


With  numerous 


illustrations.     In  one  neat  royal  12mo.  volume.      {In  Press.) 


T 


BANNER  [THOMAS  H.),  M.D. 
ON  THE  SIGNS  AND  DISEASES  OF  PREGNANCY.    First  American 

from  the  Second  and  Enlarged  English  Edition.      With  four  colored  plates  and  illustra- 
tions on  wood.     In  one  handsome  octavo  volume  of  about  500  pages,  cloth,  $4  25. 


rpHE  OBSTETRICAL  JOURNAL.     {Free  of  postage/or  1619.) 

THE  OBSTETRICAL  JOURNAL  of  Great  Britain  and  Ireland; 

Including  Midwifery,  and  the  Diseases  op  Women  and  Infants.  With  an  American 
Supplement,   edited  by  J.  V.  Ingham,   M.D.     A  monthly  of   about  96  octavo  pages, 
very  handsomely  printed.  Subscription,  Five  Dollars  per  annum.     Single  Numbers,  60 
cents  each. 
Commencing  with  April,  1873,  the  Obstetrical  Journal  consists  of  Original  Papersby  Brit- 
ish  and   Foreign    Contributors  ;   Transactions   of   the   Obstetrictil   Societies   in  Enghind  and 
abroad.    Reports  of  Hospital   Practice;   Reviews  and    Bibliographical    Notices;    Articles  and 
Notes,   Editorial,   Historical,   Forensic,  and   Miscelltineous  ;  Selections  from  Journals;   Cor- 
respondence, <fec     Collecting  together  the  vast  amount  of  material  daily  accumulating  in  this 
important  and   rapidly  improving  department  of  medical  science,  the   value  of  the   infor- 
mation which  it  presents  to  the  subscriber  may  be  estimated  from  the  character  of  the  gen- 
tlemen who  have  alreadj  promised  their  support,  incluiling  such  names  as  those  of  Drs.  At- 

THILL,    AVKI-ING,   RoB  ERT  B  A  RNES,  J.  HeNR>    6  E  NN  ET,  N  ATI!  A  N    BoZKMAN,   ThOM  AS  C  H  A  M  B  E  RS  , 

Fleetwood  Ciicrchill,  Charlks  Cl.\y,  John  Clay,  Matthews  Duncan,  Arthur  Farre, 
Robert  GitBE-snALOH,  Graily  Hewitt,  Braxton  Hicks,  Alfred  Meadows,  W.  Lkisu- 
MAN,  Alex.  Simpson,  IIeywood  Smith,  Tyler  Smith,  Edward  J.  Tilt,  Lawson  Tait, 
Spencer  Wells,  Ac.  &c.  ;  in  short,  the  representative  men  of  British  Obstetrics  and  Gynas- 
cology.    . 

In  order  to  render  the  Obstetrical  Journal  fully  adequate  to  the  wants  of  the  Ameri- 
can profession,  each  number  contains  a  Supplement  devotetl  to  the  advance.*  made  in  Obstet- 
rics and  gynaecology  on  this  side  of  the  Atlantic.  This  portion  of  the  Journal  is  under 
the  editorial  charge  of  Dr.  J.  V.  Ingham,  to  whom  editorial  communications,  exchanges, 
books    for    reriew,  Ac,  may  be  addressed,  to  the  care  of  the  publisher. 

♦**  Complete  sets  from  the  beginning  can  no  longer  be  furnished,  but  subscriptions  can 
com'Qence  with  January,  1879,  or  Vol.  Vil.,  No.  1,  April,  1879. 


Henry  C.  Lea's  Publications — {Midwifery^  Surgery).  25 

TEISHMAN  (  WILLIAM),  M.D., 

Regiun  Pro/fssor  of  Mitiwi/t-ry  in  the.  Untverxity  nf  Glaxgow,  Ac. 

A  SYSTEM  OF  MIDWIFERY,  IiN'CLUDING  THE  DISEASES  OF 

PREGNANCY  AND  THE  Pl'ERPERAL  STATE.  Third  American  edition,  will)  addi- 
tions  by  John  S.  Paukv,  M.D.,  Obstetrician  to  the  Philiidelpiiia  llduiiiial.  <ic.  In  one 
large  and  very  handsome  octavo  volume,  with  about  two  hundred  illustrations.   (S/tcn-t/y.) 

JpARRY  {JOHN  S.).  M.D., 

ObHHricinn  to  the  Philadelphia  Hospital,  Vice-Prettt.  of  the  Ohstet.  Steiety  of  Philadelphia. 

EXTRA-UTERINE    PREGNANCY:    ITS  CLINICAL  HISTORY, 

DIAGNOSIS,    PROGNOSIS,  AND    TREATMENT.     In   one  handsome  octavo  volume. 
Cloth,  $2  uO.     {Latehj  Issued.) 


H 


ODGE  [HUGH  L.),  M.D., 

Emeritus  Profesxor  of  Midwifery,  *e.,  in  the  University  of  Pennsylvania,  &c. 

THE  PRINCIPLES  AND  PRACTICE  OF  OBSTETRICS.  Illus- 
trated with  large  lithographic  plates  containing  one  hundred  and  fifty-nine  figures  from 
original  photographs,  and  with  numerous  wood-cuts.  In  one  large  and  beautifully  printed 
quarto  volume  of  550  double-columned  pages,  strongly  bound  in  cloth,  $14. 

The  work  of  Dr.  Hodge  is  something  more  than  sabjecl  it  is  decidedly  the  best.— £rfm6.  itfed.  J^oitr., 
a  simple  presentation  of  his  particalar  views  in  the    Dec.  iSiii. 

department  of  Obstetrics;  it  is  something  more  ^g  ^ave  read  Dr.  Hodge's  book  with  great 
thanan.rdinarytreat.seonmidwiferyjitis mfact,  pleasure,  and  have  much  satisfaction  in  express- 
a  cyclopedia  of  midwifery.  He  has  aimed  to  em-  ■  ^^^  commendation  of  it  as  a  whole.  It  is  cer- 
boay  ina  ,mgle  volume  the  whole  science  and  art  of :  ^.^^^^  j^j  ^ly  instructive,  and  in  the  main,  we  be- 
Obstetncs      An  elaborate  text  is  combined  with  ac-    ^^  ,o„g,t      The  great  attention  which  the  au- 

cui-ate  and  varied  pictorial  illustrations,  so    hat  no    ^^^^  ^^^  devoted  to  tie  mechanism  of  parturition, 
\   °'l'Tl^-^   ''  i^"  '^fiV^f,    °''  '^"^^Plai'is'l-    taken  along  with  the  conclusions  at  which  he  has 
-Am.  Med.  Times,  sept.  3,  1S64.  arrived,  point,  we  think,  conclusively  to  the  fact 

It  18  very  large,  profuselyand  elegantly illnstrat-i  that,  in  Britain  at  least,  the  doctrines  of  Naegela 
ed,  and  is  fitted  to  take  its  plaee  near  the  works  of!  have  been  too  blindly  recei-ved.  —  Glasffow  Med. 
great  obstetricians.     Of  the  American  works  on  the  I  Journal,  Oct.  1864. 

^*^  Specimens  of  the  plates  and  letter-press  will  be  forwarded  to  any  address,  free  by  mail, 
on  receipt  of  six  cents  in  postage  stamps. 


DAMSB0THA3I  [FRANCIS  H.),  M.D. 

THE  PRINCIPLES  AND  PRACTICE  OF  OBSTETRIC  MEDI- 
CINE AND  SURGERY,  in  reference  to  the  Process  of  Parturition.  A  new  and  enlarged 
edition,  thoroughly  revised  by  the  author.  With  additions  by  W.  V.  Keating,  M.  D., 
Professor  of  Obstetrics,  Ac,  in  the  Jefferson  Medical  College,  Philadelphia.  In  one  liree 
and  handsome  imperial  octavo  volume  of  650  pages,  strongly  bound  in  leather,  with  rai.=ed 
bands  ;  with  sixty-four  beautiful  plates,  and  numerous  wood-cuts  in  the  text,  containing  in 
all  nearly  200  large  and  beautiful  figures.     $7  00. 


OTIMSON  [LEWIS  A.),  A.M.,  M.D., 

'^  Surgeon  to  the  Preshyteria^n  Hospital. 

A  MANUAL  OF  OPERATIVE  SURGERY.     In  one  very  liand.some 

royal  12mo.  volume  of  about  500  pages,  with  332  illustrations  ;  cloth,  $2  bO.(Now  Ready  ) 
The  work  before  us  is  a  well  printed,  profu-ely  ,  performing  them.  The  work  is  handsomely  illns- 
illttstrated  manual  of  over  four  hundred  and  seventy  !  tiated,  anil  the  def  criptions  are  clear  and  well'drawn. 
pages.  The  norice,  by  a  perusal  of  the  work,  will  j  It  is  a  clever  and  useful  volume;  every  student 
gain  a  good  idea  of  the  geurtral  domain  of  operative  |  should  possess  one.  The  preparation  of  this  work 
surgery,  while  the  practical  surgeon  has  presented  I  does  away  with  the  necessity  of  pondering  over 
to  him  within  a  very  concise  and  intelligible  form  |  larger  works  on  surgery  for  descriptions  of  opera- 
the  latest  and  most  approved  selections  of  operative  [  tions,  as  it  presents  in  a  nutshell  just  what  is  wanted 


procedure.  Theprec'sion  aid  conciseness  with  which 
the  different  operations  are  described  enable  the 
author  to  compress  an  immense  amount  of  practical 
informatiou  in  a  very  small  compass. — N.  Y.  Medical 
Record,  Aug.  3,  1S7S. 

This  volume  is  devoted  entirely  to  operative  sur- 
gery, and  is  intended  to  familiarize  the  studeot  with    — Cincinnati  Lancet  and  Clinic,  July  27,  1S7S 
the  details  of  operations  and  the  different  modes  of 


by  the  surgeon  without  an  elaborate  search  to  find 
it. — Jlfd.  Med  Journal,  Aug.  1S78. 

The  author's  conciseness  and  the  repleteness  of 
the  work  with  valuable  illustrations  entitle  it  to  be 
classed  with  the  text-books  for  students  of  operative 
surgery,  and  as  one  of  reference  to  the  prHctilioner. 


SKBY'S   OPEEATIVE  SURGERY.     In  1  vol.  8vo.  |  Nbill,  M.D. ,  Professor  of  Surgery  in  the  Penna. 

cl.,  of650pag«8  ;  with  about  100  wood-cuts.  $3  25.  '  Medical  College,  Surg' n  to  the  Pennsylvania  Hos- 

nnoPFR'S  TFrTmfTTR  ONTHTTPRTxrTPTVSANTil  P>tal,&c.     In  one  very  handsome  octavo  vol.   of 

COOPER  S  LECTURES  ON  THE  PRINCIPLES  AND  !  730              .^jth  316  illustrations,  cloth,  *3  75. 

PtiCTiCEOFSuHOBBT.  Inl  vol.  8vo.crh,750p.  $2.  r   =     1                                             .            , 

^  MILLER'S  PKINCIPLESOF  SURGERY.  Fourth  Ame- 

GIBSON'S  INSTITUTES  AND  PRACTICE  OF  SUR-  i  rican,  from  the  Third  Edinburgh  Edition.     In  one 

SERT.  Eighth  edit'n,  improved  and  altered.  With  large  8vo.  vol.  of  700  pages,  with  340  illustrations, 

thirty-four  plates.     In  two  handsome  octavo  vol-  cloth,  $3  75. 

umes.abontlOOOpp.. leather. raised  bandp.  U6  50.  MILLER'S  PRACTICE  OF  SURGERY.  Fourth  Am e- 

THE  PRINCIPLES  AND  PRACTICE  OF  SURGERY.  !  rican,  from  the  last  Edinburgh  Edition.  i>evised  by 

By  William  Pirrie,  F.R  S.E.,  Profes'r  of  Surgery  |  the  American  editor.  In  on  e  large  8  vo.  vol.  of  nearly 

in  the  University  of  Aberdeen.    Edited  by  John  1  700  pages,  with  364  illustrations:  clotb,  $3  75 


26 


Hexry  C.  Lea's  Publications — {Surgery  . 


fiROSS  {SAMUEL  D.),  M.D., 

^-^  Professor  of  Surgery  in  the  Jefferson  Medical  College  of  Philadelphia. 

SYSTEM  OF    SURGERY:   Pathological,  Diagnostic,  Therapeutic, 

and  Operative.    Illustrated  by  upwards  of  Fourteen  Hundred  Engravings.   Fifth  editioii 
carefully  revised,  and  improved.  In  two  large  and  beautifully  printed  imperial  octavo  vol- 
umes of  about  2300  pp.,  strongly  bound  in  leather,  with  raised  bands,  $16.    (Just  Issued. ' 
The  continued  favor,  shown  by  the  exhaustion  of  successive  large  editions  of  this  great  work, 
proves  that  it  has  successfully  supplied  a  want  felt  by  American  practitioners  and  students.     In 
th(  present  revision  no  pains  have  been  spared  by  the  author  to  bring  it  in  every  respect  fully 
up  tc  the  day.     To  effect  this  a  large  part  of  the  work  has  been  rewritten,  and  the  whole  en- 
arged  bj  aearly  one-fourth,  notwithstanding  which  the  price  has  been  kept  at  its  former  very 
moderatf  rate.     By  the  use  of  a  close,  though  very  legible  type,  an  unusually  large  amount  of 
matter  is  Jondensed  in  its  pages,  the  two  volumes  containing  as  much  as  four  or  five  ordinary 
octavos     This,  combined  with  the  most  careful  mechanical  execution,  and  its  very  durable  bind 
ing  render? ,  it  one  of  the  cheapest  works  accessible  to  the  profession.     Every  subject  properly 
belonging  to  the   lomain  of  surgery  is  treated  in  detail,  so  that  the  student  who  possesses  this 
work  may  be  said  to  have  in  it  a  surgical  library. 


We  have  now  brought  our  task  to  a  conclusion,  and 
have  seldom  read  a  work  with  the  prfiotical  v»lue  of 
which  we  have  been  moreimpresped.  Every  chapter  is 
so  concisely  put  together,  that  the  busy  practiiioner. 
when  in  difficulty,  cau  at  once  find  theinformation  he 
requires.  His  work,  on  the  contrary,  i.s  cosmopolitan, 
the  surgery  of  the  world  being  fully  repre.=ented  in  it. 
The  work,  in  fact,  is  so  historically  unprejudiced,  and 
so  eminently  practical,  tliat  it  is  almost  a  false  compli 
iiient  to  say  tliatwe  believe  it  to  be  destined  to  occupy 
a  foremost  place  as  a  work  of  reference,  while  a  system 
of  surgery  like  the  present  system  of  surgery  is  the 
practice  of  surgeons.  The  printing  and  binding  of  the 
•work  is  unexceptionable;  indeed,  it  contrasts,  in  the 
latter  respect,  remarkably  with  Eniilish  medical  anri 
surgical  cloth-bound  publications,  which  arc  generally 
so  wretchedly  stitched  as  to  require  re-binding  before 
they  are  anv  time  in  use. — Vv.b.  Journ.  (if  Med.  Sci.. 
March,  1874. 

Dr.  Gross's  Surgery,  a  great  work,  has  become  still 
greater,  both  in  size  and  merit,  in  its  most  recent  form. 
The  difference  in  actual  number  of  pages  is  not  more 
than  1.30,  but.  the  size  of  the  page  having  been  in- 
creased to  what  we  believe  is  technically  termed  "•ele- 
phant." there  has  been  roomforconsiderabloadditions, 
•which,  together  with  the  alterations,  are  improve- 
ments.— Land.  Lancet,  Nov.  16, 1S72. 

It  combines,  as  perfectly  as  possible,  the  qualities  of 
a  text-book  and  work  of  reference.   Wv  think  this  last 


elition  of  Gross's  "  Surgery,"  will  confirm  his  title  of 
•'  Primus  inter  Pares."  It  is  learned,  scbolar-like,  me- 
thodical, precise,  and  exhaustive.  We  scarcely  think 
any  living  man  could  write  so  complete  and  faultless  a 
treatise,  or  comprehend  more  solid,  instructive  matter 
in  the  given  number  of  pages.  The  labor  must  have 
been  immense,  and  the  work  gives  evidence  of  great 
powers  of  mind,  and  the  highest  order  of  intellectual 
discipline  and  methodical  disposition,  and  arrangement 
of  acquired  knowledge  and  personal  experience. — JS'.Y. 
Med.  Journ.,  Feb.  1873. 

As  a  whole,  we  regard  the  work  as  the  representative 
"Sy.stem  of  Surgery"  in  the  English  language. — St. 
Louis  Medical  and  Surg.  Journ.,  Oct.  1872, 

The  two  magnificent  volumes  before  us  afford  a  very 
complete  view  of  the  surgical  knowledge  of  the  day. 
Some  years  ago  we  had  the  pleasure  of  presenting  the 
first  edition  of  Gross's  Surgery  to  the  profession  as  a 
work  of  unrivalled  excellence;  and  now  'we  have  the 
result  of  years  of  experience,  labor, and  study,  all  con- 
densed upon  the  great  work  before  us.  And  to  students 
or  practitioners  desirous  of  enriching  theirlibrary  with 
a  treasure  of  reference,  we  can  simply  commend  the 
purchase  of  these  two  volumes  of  immense  research  — 
Cincinnati  Lancet  and  Observer,  Sept.  Ic72. 

A  complete  system  of  surgery — not  a  mere  text-book 
of  operations,  but  a  scientific  account  uf  surgical  theory 
and  practicein  all  its  departments. — Brit,  and  For. 
M'd  Chir.  Rev.,  .Tan.  1873. 


Vr  THE  SAME  AUTHOR. 

A    PRACTICAL  TREATISE    ON  THE  DISEASES,  INJURIES, 

and  Malformations  of  the  Urinary  Bladder,  the  Prostate  Gland,  and  the  Urethra.  Third 
Edition,  thoroughly  Revised  and  Condensed,  by  Samuel  W.  Gross,  M.D.,  Surgeon  to 
the  Philadelphia  Hospital.  In  one  handsome  octavo  volume  of  574  pages,  with  170  illus- 
trations :  cloth,  $4  50.  (Just  Issued.) 
For  reference  and  general  information,  the  physician  leases  of  the  urinary  organs. — Atlanta  Med.  Journ.,  Oct. 
or  surgeon  can  find  no  work  that  meets  their  necessities    1876. 


more  thoroughly  than  this,  a  revised  edition  of  an  ex- 
cellent treatise,  and  no  medical  library  should  be  with- 
out it.  Replete  with  handsome  illustrati'ins  and  good 
ideas,  it  has  the  unusual  advantage  of  being  easily 
comprehended, by  the  reasonableand  practical  manner 
in  which  the  various  subjects  are  sy.-tematized  and 
arranged     We  heartily  recommend  it  to  the  profi 


It  is  with  pleasure  we  now  again  take  up  this  old 
work  in  a  decidedly  new  dress.  Indeed,  it  must  be  re- 
garded as  a  new  book  in  very  many  of  its  parts.  The 
cliapters  on  -'Diseases  of  the  Uladder,"  "Prostate 
Body,"  and  "Lithotomy,"  are  splendid  specimens  of 
descriptive  writing;  while  the  chapter  on  '•Stricture" 

one  of  the  most  concise  and  clear  that  we  have  ever 


a' a  valuable  addition  to  the  important  literature  of  dis-irg,,j__;\-g^  York  Med.  Journ. .Noy.lS'6. 


THE 


r)T  THE  SAME  AUTHOR. 

A   PRACTICAL   TREATISE    ON   FOREIGN  BODIES    IN 

AIR-PASSAGES.     In   1  vol.  8vo.,  with  illustrations,  pp.  468,  cloth,  $2  75. 

T)RUITT  {ROBERT),  M.K.C.S.,  ^c. 

THE  PRINCIPLES  AND  PRACTICE  OF  MODERN  SURGERY. 

A  new  and  revised  American,  from  the  eighth  enlarged  and  improved  London  edition.  Illut- 
trated  with  four  hundred  and  thirty-two  wood  engravings.  In  one  very  handsome  octa'^o 
volume,  of  nearly  700  large  and  closely  printed  pages,  cloth,  $4  00  ;  leather,  $6  00. 

practice  of  surgery  are  treated,  and  so  clearly  and 
perHpicuously,  auto  elucid  ate  e  very  i  mportHn  1  topii . 
Wo  aave  examined  thebook  mostthoroughly,  and 
cau  my  that  tliiH  succeHsiB  well  merited.  His  book 
moreover,  poHBessew  the  inestimable  advantages  of 
having  the  subjectB  perfectly  well  arranged'  acd 
clafsilled  and  of  being  written  in  a  style  at  once 
clear  ind  Buccinct. — Atn.  Journal  of  Med.  Scienvee. 


All  that  the  Hurgical  student  or  practilionercould 
desire. — Dublin  Quarterly  JmirniU. 

It  is  a  most  admirable  book.  We  do  not  know 
irhen  we  have  examined  one  with  more  pleasure. — 
Boston  Med.  and  Surg.  Journal. 

In  Mr.  Draltt 'shook,  though  containing  only  some 
seven  hundred  pages,  both  the  principles  and  the 


Henry  C  Lea's  Publications — (Surgery). 


27 


J  SHHURST  [JOHN,  Jr.),  M.D., 

-^^  I'roJ.  I'f  Clinical  Surf/>:ri/.  i'tiiv.  of  Pa.,  Surgeon  to  the  Episcopal  Hospital,  Philadelphia 

THE    PRINCIPLES  AND  PRACTICE  OF  SURGERY.     Second 

edition,  enlarged  and  revised.  In  one  very  large  and  handsome  octavo  volume  of  over 
1000  pages,  with  542  illustrations.  Cloth,  $6;  leather,  $7.  {Just  Rendi/.) 
CoiiscioDtiousness  and  tlioi-ooglinesH  are  two  very  Aslihurit's  Surgery  is  loo  well  known  in  thi.s 
marked  trails  of  cliaiacter  in  the  author  of  this  country  to  roquh-;  i-pecial  commeiidalion  fi-oin  us 
l/ook.  Hut  of  these  trails  largely  has  grown  the  This,  its  second  edition,  enlarged  and  thorouifhiy 
bucceKs  of  his  mental  fruit  In  the  past,  and  the  pre-  |  revised,  brings  it  nearer  oiii-  idea  of  a  model  text- 
sent  olfer  seems  in  no  wise  an  exception  to  what  has  j  book  than  any  recently  published  treatise.  Thou"h 
gone  bffore.  The  general  arrangement  of  the  vol-  numerous  additions  have  been  made,  the  size  of  the 
ume  is  the  same  as  in  the  first  eililion,  but  every  pdrt  work  is  not  materially  increased  'I'he  main  trooble 
has  been  carefully  revised,  and  much  new  matter  ;  of  text-books  of  modern  times  is  that  they  are  too 
added. — Phila.  Med.  Timeti,  Feb.  1,  1S79.  i  cumbersome.     The  student  noeds  a  book  which  will 

furnish   him    the  riio.-t  information  in  the  shortest 


We  have  previouely  spoken  of  Dr.  Ashhursfs 
work  in  terms  of  praise.  We  wish  to  reiterate  those 
terms  here,  and  to  add  that  no  more  satisfactory 
representation  of  midern  surgery  has  yet  fallen 
from  the  press.  In  point  of  judicial  fairness,  of 
power  of  condeusatiou,  of  accuracy  aud  conciseoess 
of  expression  and  thoroughly  good  Kiiglish,  Prof. 
Ashhurst  has  no  superior  among  ilie  surgical  writers 
in  America. — Am.  Practitiuner,  Jan.  1679. 

The  attempt  to  embrace  iu  a  volume  of  1000  pages 
the  whole  field  of  surgery,  general  and  special, 
would  be  a  hopeless  ta^k  unless  throcgh  the  most 
tireless  industry  in  collating  and  arranging,  and 
the  wisest  judgment  in  condensing  and  excluding. 
These  facilities  have  been  abundantly  employed  by 
the  author,  and  he  has  given  us  a  most  excellent 
treatise,  brought  up  by  the  revision  for  the  second 


time  In  every  respect  this  work  of  Ashhurst  is 
the  model  text-book- full,  comprehensive  and  com- 
pact.—yn.vkvi  He  Jour  of  Med.  rmd  Surg.,  .Jan.  '79. 
The  favorable  r.ception  of  the  fir^t  edition  is  a 
guarantee  of  the  popularity  of  this  tdiiiou,  which  is 
fresh  from  the  edit<ir's  hands  with  many  enlarge- 
ments and  improvements.  The  author  of  this  work 
is  doNervedly  popular  as  an  editor  and  writer,  and 
his  Contributions  to  the  literature  of  -nrgery  have 
gained  for  him  wide  reputation.  The  volume  now- 
offered  the  profession  will  add  new  laurels  to  those 
already  won  by  previous  contribution.?.  We  can 
only  add  that  the  work  is  well  arranged,  filled  witli 
practical  matter,  and  contains  in  brief  and  clear 
langua-e  all  that  is  necessary  to  be  learned  by  the 
student  of  surgery  whilst  in  aclendauce  upon  lec- 
nres,  or  the  general  practitioner  in  his  daily  routine 


edition  to  the  latest  d>iie.    Of  course  this  bonk  is  not     practice. — M<1.  Med.  Journal,  Jan.  1S79. 


deeigued  for  specialists,  but  as  a  course  of  general 
surgical  knowledge  aud  for  general  practitioners, 
and  as  a  text-book  for  students  it  is  not  surpassed 
by  any  that  has  yet  appeared,  whether  of  lume  or 
foreign  authorship. — if.  Carolina  Med.  Journal, 
Jan.  1S79. 


The  fact  that  this  work  has  reached  a  second  edi- 
tion so  very  soon  after  the  publication  of  the  first 
one,  speaks  more  highly  of  its  merits  than  anything 
we  might  say  in  the  way  of  commendation.  U 
seems  to  have  immediately  gained  the  favor  of  stu- 
dents and  physicians.— o'iTit-tn.  Med.  Nkw-s,  Jan.  '79 


'DRYANT  [THOMAS),  F.R.G.S., 

^-^  Surgeon  to  Ouy'g  Hospital. 

THE  PRACTICE  OF  SURGERY.     Second  American,  from  the  Sec- 

ond  and  Revised  English  Edition.     With  Six  Hundred  and  Seventy-two  Engravings  on 
Wood.     In  one  large  and  very  handsome  imperinl  octavo  volume  of  over  lUUU  lar^e  and 
closely  printed  pages.     Cloth,  $6;   leather,  §7.      {Just  Ready.) 
This  work  has  enjoyed  the  advantage  of  two  thorough  revisions  nt  the  hand  of  the  author  since 
the  appearance  of  the  first  American  edition,  resulting  in  a  very  notable  enlargement  of  size  and 
improvement  of  matter.     In  Enghmd  this  has  led  to  the  division  of  the  work  into  two  volumes' 
which  are  here  comprised  in  one,  the  size  being  increased  to  a  large  imperial  octavo,  printed  on 
a  condensed  but  clear  type.      The  series  of  illustrations  has  undergone  a  like  revision,  and  will 
be  found  correspondingly  impro^  ed. 

The  marked  success  of  the  work  on  both  sides  of  the  Atlantic  shows  that  the  author  has  suc- 
ceeded in  the  effort  to  give  to  student  and  practitioner  a  sound  and  trustworthy  guide  in  the 
practice  of  Curgery;  while  the  simultaneous  appearance  of  the  present  editi.-^n  in  England  and 
in  this  country  affords  to  the  American  reader  the  benefit  of  the  most  recent  advanceo  made 
abroad  in  surgical  science. 

There  are  so  many  text-books  of  surgery,  so  many  Another  edition  of  this  manual  ha  .ing  been  called 
written  by  skilled  and  distinguished  hands,  that  to  ob-  for,  the  author  has  availed  hiuiselfof  the  oppoitunity 
tain  the  houor  of  a  third  edition  in  iiugland  is  no  light  |  to  make  no  few  alterations  in  the  scboiauce  as  we  I 
praise.  Mr.  Bryant  merits  this,  by  clearness  of  style,  ,  as  in  the  arrangement  of  the  work,  and,  wiih  a  view 
and  good  judgment  in  selecting  the  operations  he  re-  to  its  improvement,  has  recast  the  materials  aud  re- 
commend.", in  his  new  editions  he  goes  carefully  over  i  vised  the  whole.     We  ourselves  are  of  the  opiuiou 

the  eld  grounds,  in  li^'ht  of  later  research.     On  these'  that  there  is   no  better  work  on  surgery  extant 

and  mauy  allied  point.-,  Mr.  liryant  is  a  calm  aud  uu-  I  Vii-cinnati  Med.  Newa,  Maich    ls7.o 
partisan  observer,  and  his  book  throughout  has  the        Bryant's  Surgery  has  been  favorably  received  from 
great  merit  of  ni.,.utain,r,g  the  true  scientific  judicial  :, he  fiV^t,  and  eviaenily  grows  in  the^eTeern  of  th^ 
toiie  of  mma.-Med.  and  Surg.  UeporUr,   March  22,  ;  profession  w.th  each  succeeding  eduion      In  glanc 

■  .  ;  lug  over  the  volumebefore  us  wefiud  proof  in  almost 

The  work  before  us  is  the  American  reprint  of  the  every  chapter  of  the  thorough  revision  which  the 

last  London  edition,  and  has  the  advantage  over  the  worK  has  undergone,  injny  parts  havinir  been  cut 

latter  in  being  of  more  convenient  size,  aud  in  being  out  and  replaced  by  matter  entirely  fresh. N.   Y. 

compressed  into  one  volume.     The  author  has  rewrit-  "'"'      .  _..:i    l.-<^ 

ten  the  greater  part  of  the  work,  and  has  succeeded, 
in  the  amount  of  new  matter  added,  in  making  it  mark- 


Med..  .'num.,  April,  lb79. 
Welcome  as  ihe  new  edition  is,  and  as  much  as  it 


is  entitled  to  commendation,  yet  its  appearance  at 
this  time  is,  in  a  certain  sense,  a  matter  of  regret,  as 
it  will  be  iu  competition  with  another  work,  lately 
issued  from  the  s^tme  press.  But,  the  diUicult  task 
of  forming  a  judgment  as  to  the  relative  merits  of 
Bryant  and  Ashhurst  we  will  not  attempt,  but  pre- 

student  andVractTtioner:-:\:'yrjv/<i<7i;r"o>rf;'>L;ch  ,  I'^'v  nthVr«  win^Hif^  the  high  e.xcelleuce  of  both. 

2-'  jS79  many  others  will  likewise  be  lorced  to  hesitate  long 

"'  ■  I  in  making  choice  between  them —C't«ct/(»(«<j  Aaa- 

cet  and  Clinic,  March  22,  ls79. 


edly  distinctive  from  previous  editions.  A  few  extni 
pages  have  been  added,  and  also  a  few  new  illustrations 
introduced.  The  publishers  have  presented  the  work 
in  a  creditable  style.  As  a  concise  and  practical  manual 
of  British  surgery  it  is  perhaps  without  an  equal,  and 
will  doubtless  always  be  a  favorite  text-book  vrith  the 


28 


Henry  C.  Lea's  Publications — (Shrgery). 


PJRICHSEN  [JOHN  E.), 

Professor  of  Surgery  in  University  College,  London,  etc. 

THE  SCIENCE  AND  ART  OF  SFRGERY ;  being  a  Treatise  on  Sur- 
gical Injuries,  Diseases,  and  Operations.  Carefully  revised  by  the  author  from  the 
Seventh  and  enlarged  English  Edition.  Illustrated  by  eight  hundred  and  sixty  two  en- 
gravings on  wood.  Ie  two  large  and  beautiful  octavo  volumes  of  nearly  2000  pages  : 
cloth,  $S  60  ;  leather,  $10  50.      (,Noto  Ready.) 

In  revising  this  standard  work  the  author  has  spared  no  pains  to  render  it  worthy  of  a  continu- 
ance of  the  very  marked  favor  which  it  has  so  long  enjoyed,  by  bringing  it  thoroughly  on  a 
level  with  the  advance- in  the  science  and  art  of  surgery  made  since  the  appearance  of  the 
last  edition.  To  accomplish  this  has  required  the  addition  of  about  two  hundred  page.'  of  text, 
while  the  illustrations  have  undergone  a  marked  improvement.  A  hundred  and  fifty  additional 
wood-cuts  have  been  inserted,  while  about  fifty  other  new  ones  have  been  substituted  for  figures 
which  were  not  deemed  satisfactory.  In  its  enlarged  and  improved  form  it  is  therefore  pre- 
sented with  the  confident  anticipation  that  it  will  maintain  its  position  in  the  front  rank  of 
text-books  for  the  student,  and  of  works  of  reference  for  the  practitioner,  while  its  exceedingly 
moderate  price  places  it  within  the  reach  of  all. 


The  seveuth  edition  is  before  the  world  as  the  la.st 
word  01  surgical  science.  There  may  be  monographs 
whicli  excel  it  upon  certain  point.s,  but  as  a  con- 
spectus upon  surgical  principles  and  practice  it  is 
unrivalled.  It  will  well  reward  pVHCtitiouers  to 
read  it,  for  it  has  been  a  peculiar  province  of  Mr. 
Erichsen  to  demoustrate  the  absolute  interdepend- 
ence of  medical  and  surgical  science  We  need 
scarcely  add,  in  conclusion,  that  we  heartily  com- 
mend the  work  to  students  that  they  may  be 
grounded  in  a  sound  faith,  and  to  practitioners  as 
an  Invaluable  guide  at  the  bedside. — Am  Practi- 
tioner, April,  1S7S. 

It  is  no  iile  compliment  to  say  that  this  is  the  best 
edition  Mr.  Erichsen  has  ever  produced  of  his  well- 
known  boon.  Besides  inheriting  the  virtues  of  iis 
predecessors,  it  possesses  excelleuces  quite  its  own. 
Having  stated  that  Mr.  Erichsen  his  incorporated 
into  this  edition  every  recent  improvement  in  the 
science  and  art  of  surgeiy,  it  would  be  a  supereroga- 
tion to  give  a  detailed  criticism.  In  short,  we  un- 
hesitatingly aver  th-tt  we  know  of  no  other  single 
work  ivhere  the  student  and  practitioner  can  gain  at 
oncesoclear  aninsight  iuto  the  principles  of  surgery, 
and  so  complete  a  knowlsdge  of  the  exigencies  of 
surgical  practice.— iojicioji  Lancet,  Feb.  11,  1878 

For  the  past  twenty  years  Erichsen's  Surgery  has 
maintained  its  place  as  the  leading  text- book,  not  only 
in  this  country,  but  in  Great  Britain.  That  it  is  able 
to  hold  its  ground,  is  abundantly  proven  by  the  tho- 
roughness wifh  which  the  present  edition  has  been 
revised,  and  by  the  large  amount  of  valuable  mate- 
rial that  has  been  added.  Aside  from  this,  cne  hun- 
dred and  fifty  uew  illustrations  have  been  inserted, 
including  quite  a  number  of  microscopical  appear- 
ances of  paih.il  .gical  processes,  cio  mirked  is  this 
change  for  the  better,  that  the  work  almost  appears 
as  an  entirely  new  one. — Med.  Record,  Feb.  23,1878. 


Of  the  many  treatises  on  Surgery  which  it  has  been 
our  task  to  study,  or  our  pleasure  to  read,  there  is  none 
which  in  all  points  has  satisfied  us  so  well  as  the  classic- 
treatise  of  Kricbsen.  His  polished,  clear  style,  liis free- 
dom from  prejudice  and  hobbies,  his  unsurpassed  grasp 
of  his  subject,  and  vast  clinical  experience,  qualify  him 
admirably  to  write  a  model  text-book.  When  we  wish, 
at  the  least  cost  of  time,  to  learn  the  most  of  a  topic  in 
surger3',  we  turn,  by  preference,  to  his  work.  It  is  a 
pleasure,  therefore,  to  see  that  the  appreciation  of  it  is 
general,  and  has  led  to  the  appearance  of  another  edi- 
tion.— Med.  and  Sing.  Mepoflfr,  Feb.  2, 1878. 

Notwithstanding  the  increase  in  size,  we  observe  that 
much  old  matter  has  been  omitted.  The  entire  work 
has  been  thoroughly  written  up,  and  not  merely  amend- 
ed by  a  few  extra  chapters  A  great  improvement  has 
been  madein  the  illustrations.  One  hundred  and  fifty 
new  ones  have  been  added,  and  many  of  the  old  ones 
have  been  redrawn  The  author  highly  appreciates  the 
favor  wiih  which  his  work  has  been  received  by  Ameri- 
can surgeons,  and  has  endeavored  to  render  bis  latest 
edition  more  than  ever  worthy  of  their  approval.  That 
be  has  succeeded  admirably,  must,  we  think,  be  the 
general  opinion.  We  heartily  recommend  the  book  to 
both  student  and  practitioner. — N.  Y.  Med.  Journal, 
Feb.  1878. 

Erichsen  has  stood  so  prominently  forward  for 
years  as  a  writer  on  Surgery,  that  his  reputation  is 
world  wide,  and  his  name  is  as  familiar  to  the  med- 
ical student  as  to  the  accomplished  and  experienced 
surgeon.  The  work  is  not  a  reprint  of  former  edi- 
tions, but  has  in  many  places  been  entirely  rewrit- 
ten. Recent  improvements  in  surgery  have  not  es- 
caped his  notice,  various  new  operations  have  been 
thoroughly  analyzed,  and  their  merits  thoroughly 
discussed.  One  hundred  and  fifty  uew  wood-cuts 
add  to  the  value  of  this  work. — N.  O.  Med.  and  Surg. 
Journal,  March,  1878. 


H 


OLMES  [TIMOTHY],  M.D., 

Surgeon  to  St.  George's  Hospital,  London. 

SURGERY,  ITS  PRINCIPLES  AND  PRACTICE.     In  one  hand- 

some  octavo  volume  of  nearly  1000  pages,  with  411  illustrations.  Cloth,  $6;  leather,  $7. 
(Jicst  Issued.) 


This  is  a  work  which  has  been  looked  for  on  both 
sides  ofthe  Atlantic  with  much  interest.  Mr.  Holmes 
is  a  surgeon  of  large  and  varied  experience,  and  one 
of  the  best  known,  and  perhaps  the  most  brilliant 
writer  upon  surgical  subjects  in  England.  It  is  a 
book  for  students — and  an  admirable  one — and  for 
the  busy  general  practitioner,  it  will  give  a  student 
all  the  knowledge  needed  to  pass  a  rigid  examina- 
tion. The  book  fairly  j  uslilles  the  high  expectalions 
that  were  formed  of  it.  Its  style  is  clear  aud  forcible, 
even  brilliant  at  times,  and  the  conciseness  needed 
to  bring  it  within  its  proper  limits  has  not  impaired 


its  force  and  distinctness.— if.  Y.  Med.  Record,  April 
14,  1876. 

It  will  be  found  a  most  excellent  epitome  of  sur- 
gery by  the  general  practitioner  who  has  not  the 
time  to  give  attention  to  more  minute  and  extended 
works  and  to  the  medical  student.  In  fact,  we  know 
of  no  one  we  can  more  cordially  recommt^nd.  The 
author  has  succeeded  well  in  giving  a  plain  and 
practical  account  of  each  surgical  injury  and  dis- 
ease, and  of  the  treatment  which  is  most  com- 
monly advisable.  It  will  no  doubt  become  a  popu- 
lar work  in  the  profession,  and  especially  as  a  text- 
book.—  Cincinnati  Med.  News,  April,  1S76. 


ASHTONONTHEDISEASES,  INJURIES,  andMAL- 
FOK.MATIONS  OF  THE  RECTUM  AND  ANUS: 
with  remarks  on  Habitual  Constipation.  Second 
American,  from  the  fourth  and  enlarged  London 
Edition.  With  illustrations.  In  one  Svo.  vol.  of 
287  pages,  cloth, ij(3  25. 


SARGENT  ON  BANDAGING  AND  OTHER  OPERA- 
TIONS OF  MINOR  SURGERY.  Sev!  edition,  with 
an  additional  chapter  on  Military  Surgery.  One 
12mo.  vol.  ol  3S3pag38,  withlSt  wood-cuts.  Cloth, 
$170. 


TTenry  C.  Lea's  Publications — (Ophthalmology). 


29 


TJAMILTON  {FRANK  H.),  M.D., 

•*-*  Profe.si>ornf  Fracturen  and  DixlofntiimK.  Ac. .in  BclUmie.  Hngp.  ^Ted.  College,  New  Torlt. 

A  PRACTICAL  TREATISE  ON   FRACTURES  AND  DISLOCi- 

TIONS.  Fifth  edition,  revised  nnrl  improved.  In  onelargeand  handsome  octavo  volume 
ofnearly  800  pages,  with  344  illustrations.  Cloth,  *5  75:  leather,  $6  75.  {Lately  hstttd.) 
This  work  is  well  known,  abroad  as  wel  I  as  at  home,  asthe  highest  authority  on  its  important 
subject — an  authority  recognized  in  the  courts  as  well  as  in  the  schools  and  in  practice — and 
again  manifested,  not  only  by  the  demand  for  a  fifth  edition,  but  by  arrangements  now  in  pro- 
gress  for  the  speedy  appe.irance  of  a  translation  in  Germany.  The  repeated  revi,-;ion.«  which  the 
author  has  thus  had  the  opportunity  of  making  have  enabled  him  to  give  the  mo.«tcarefuI  consid- 
eration to  every  portion  of  the  volume,  and  he  has  sedulously  endeavored  in  the  present  issue, 
to  perfect  the  work  by  the  aid  of  his  own  enlarged  experience,  and  to  incorpor.-ite  in  it  whatever 
of  value  has  been  added  in  this  department  since  the  i.«sue  of  the  fourth  edition.  It  will  there- 
fore be  found  considerably  improved  in  matter,  while  the  most  careful  attention  has  been  paid 
to  the  typographical  execution,  and  the  volume  is  presented  to  the  proftssion  in  the  confident 
hope  that  it  will  more  than  maintain  its  very  distinguished  reputation. 

of  its  teachings,  but  also  by  reason  of  the  medico-legal 
bearin;:s  of  the  case.sof  which  it  treats,  and  whifh  have 
recently  been  the  subject  of  useful  papers  by  Dr  Hamil- 
ton and  others,  is  sufficiently  obvious  to  every  one.  The 
present  volume  seems  to  amply  fill  all  the  requi.'^ites. 
We  can  safely  recommemJ  it  as  the  best  of  its  kind  in 

the  English  laneuajje.  and  not  excelled  in  any  other 

Jnurii.iif  Ntrvousand  Mental  Disease,  Jan  1876. 


There  is  no  l)etter  work  on  the  subject  in  existence 
than  that  of  Dr.  Hamilton.  It  should  be  in  the  posses- 
8ii>n  of  every  ceneral  practitioner  and  surjreon.— T/if 
Jin.  Jnurti.  of  Obstetrics.  Feb.  187C. 

The  value  of  a  work  like  this  to  the  practical  phj'si- 
cian  andsuriteon  can  hardly  beover-eslimiited.and  the 
neces.-iity  of  havin;:  such  a  lionk  revised  to  the  latest 
datB'J,  nntmer.-lv  nn  account  of  the  practical  importance 


^EOWNE  {EDGAR  A.), 

Surgeon  to  the  Livt.rpool  Eye  and  Enr  Infirmary,  and  to  the  Dinpensaryfor  Skin  Di/tenses. 

HOW  TO  USE  THE  OPHTHALMOSCOPE.     Being  Elementniy  In- 

structions  in  Ophthalmoscopy,  arranged  for  the  Use  of  Students.    M'  ith  thirty-five  illustia- 
tions.     In  one  small  volume  royal  12mo.  of  120  pages:  cloth,  $1.      {JSow  lieudy.) 


This  capital  little  work  should  be  in  the  hands  of 
ev-ry  medical  student,  and  we  had  almost  said  every 
general  practitinner.  Its  explanation  of  the  optiCHl 
principles  on  which  the  ophtbalmoscope  is  founded, 
is  60  clear  and  simple  that  the  most  stupid  reader 


could  scarcely  fail  of  understanding  them.  Equally 
satisfactory  are  the  directions  for  tlie  use  of  the  in- 
strument and  the  suggestions  to  aid  in  interpreting 
what  is  seen. — JJttrott  lUed.  Journ.,  Kot.  1877. 


o 


'ARTER  {R.  BRUDENELL),  F.R.C.S., 

ophthalmic  Surgeon  to  St.  George's  Hospital,  etc. 

A  PRACTICAL  TREATISE  ON  DISEASES  OF  THE  EYE. 


Edit- 


ed, with  test-types  and  Additions,  by  John  Green,  M.D.  (of  St.  Louis,  Mo.).  In  one 
handsome  octavo  volume  of  about  50(J  pages,  and  124  illustrations.  Cloth,  $3  76.  (Just 
Issued.) 

manner,  easy  of  comprehension,  and  hence  the  more 
valuable.   We  would  especially  commend,  however,  as 
worthy  of  high  praise,  the  manner  iu  which  the  thera- 
peutics of  di.>*ease  of  the  eye  is  elaborated,  for  here  the 
author  i.s  particularly  clear  and  practical,  where  other 
writers  are  unfortunately  too  ofien  deficient.  The  final 
chapter  is  devoted  to  a  discus>ion  ot  the  use.oand  selec- 
tion of  spectacles,  and  is  admirably  compact,  plain,  and 
useful,  e.>;pecially  the  paragraphs  on  the  treatment  of 
presbyopia  and  myopia.  In  conclusion,  our  thanks  are 
due  the  author  for  many  useful  hints  in  the  great  sub- 
It  IS  with  great  pleasure  that  we  can  endorse  the  work  Ijjjct  of  ophthalmic  ,-urgery  and   therapeutics    afield 
as  a  most  valuable  contribution  to  practical  ophthal-    where  of  late  years  we  glean  but  a  few  <'raiu«  of  s.uii.d 
mology.  Mr.  Carter  never  deviates  trom  the  end  he  has     ^jjg^t  from  amass  of  chaff —A-eto  Yurk  Mdicul  liecord 
in  view,  and  presents  the  subjectin  a  clear  and  concise  |  Qgj  23   1875.  ' 


It  would  be  difficult  for  Mr.  Carier  to  write  an  unin- 
Btructive  book,  and  impossible  for  him  to  write  an  un- 
intere.-tingone.  Kven  on  subjects  with  which  he  is  not 
bound  to  be  familiar,  hecan  discourse  with  a  rare  degree 
of  clearness  and  effect.  Our  readers  will  therefore  not 
be  surprised  to ',earn  that  a  work  by  him  on  the  Diseases 
01  the  hive  makes  a  very  valuable  addition  to  ophthal- 
mic literature.  .  .  .  The  book  will  remain  one  useful 
alike  to  the  general  and  thespecial  practitioner. — Lon- 
don Lancet,  Oct.  ZO,lS'o. 


'^ELLS  {J.  SOELBERG), 

Professor  of  Ophthalmology  in  King's  College  Hospital,  &c. 

A  TREATISE  ON    DISEASES  OF  THE  EYE.     Third  American, 

from  the  Fourth  and  Revised  London  Edition,  with  additions  ;  illustrated  with  numerous 
engravings  on  wood,  and  six  colored  plates.  Together  with  selections  from  the  Test-types 
of  Jaeger  and  Snellen.    In  one  large  and  very  handsome  octavo  volume.    (Pre2>ari7ig.) 

J  A  URENCE  {JOHN  Z.),  F.  R.  C.S., 

"^  Editor  of  the  Ophthalmic  Review,  &c. 

A  HANDY-BOOK  OF  OPHTHALMIC  SURGERY,  for  the  use  of 

Practitioners.  Second  Edition,  revised  and  enlarged.  With  numerous  illustrations.  In 
one  very  handsome  octavo  volume,  cloth,  $2  76. 

TAWSON  {GEORGE),  F.R.C.S.  Engl., 

"^  Assistant  Surgeon  to  the  Royal  London  Ophthalmic  Hospital,  Moorflelds,  &c . 

INJURIES  OF  THE  EYE,  ORBIT,  AND  EYELIDS:  their  Imme- 


diate and  Remote  Effects.     With  about  one  hundred  illustrations, 
some  octavo  volume,  cloth,  $3  60. 


In  t  ne  very  hand- 


30  Hexrt  C.  Lea's  Publications — {Iledical  Jurisprudence). 

jyURNETT  {CHARLES  H.),  M.A  ,  M.D., 

-*-^  Aural  Surg,  to  the  Presb.  Mosp.,  Surgeon-in-i:'harge  nf  the  Injlr  for  Dis .  of  the  Ear,  Pkila. 

THE    EAR,  ITS    ANATOMY.   PHYSIOLOGY,  AND    DISEASES. 

A  Practical  Treatise  for  the  Use  of  Medical  Students  and  Practitioners.  In  one  hand- 
some octavo  volume  of  615  pages,  with  eighty-seven  illustrations  :  cloth,  $4  50  ;  leather, 
$5  50.      {Just  Ready.) 

Recent  progress  in  the  investigation  of  the  structures  of  the  ear,  and  advances  made  in  the 
modes  of  treating  its  diseases,  would  seem  to  render  desirable  a  new  work  in  which  all  the  re- 
sources of  the  most  advanced  science  shouid  be  placed  at  the  disposal  of  the  practitioner.  This 
it  has  been  the  aim  of  Dr.  Burnett  to  accomplish,  and  the  advantages  which  he  has  enjoyed  in 
the  special  study  of  the  subject  are  a  guarantee  that  the  result  of  his  labors  will  prove  of  service 
to  the  profession  at  large,  as  well  as  to  the  specialist  in  this  derartment. 

Foremost  among  the  numerous  recent  contribn-  medical  stndeut,  and  its  study  will  well  repay  the 
tions  to  aural  literatare  will  be  ranked  this  work  busy  pracntioner  in  the  pleasaie  he  will  derive  from 
of  Dr.  Burnett.  It  is  impossible  to  do  justice  to  the  agreeable  style  in  which  many  otherwise  dry 
this  volume  of  over  600  pages  in  a  necessarily  brief  au.l  mos;iy  unknown  subjects  are  treated.  To  the 
notice.  It  must  suflRce  to  add  that  tbe  booi  is  pro-  sjiecialist  the  wurk  is  of  the  highest  value,  and  bis 
fasely  and  accurately  illnsrratef!,  the  references  are  sense  of  graiitude  to  Dr.  Burnett  will,  we  hope,  be 
conscientiously  acknowledged,  while  tbe  result  has  proportionate  to  ihe  amount  of  benefit  1:6  can  obtain 
been  to  produce  a  treatise  which  wiil  hencefortti  from  the  careful  study  of  ibe  book,  and  a  constant 
rank  with  the  classic  writings  of  Wilde  and  Von  reference  to  its  trustworthy  pages. —  Edinbu  gh 
Trolsch.— TAe  Land.  Prattiti'.ncr,  May,  1S79  Med.  -Jour.,  Aug.  1S7S. 

„  ^    . ,,  I    j„         ,  „!,;  i,i,„^„i.„o^        The  book  is  designed  especially  for  tbe  nse  of  .-tu- 

On  account  of  the  great  advances  which  have  been  ,^^^  ,^^  |raciitioners,  and  places  at  their 

made  of  late  years  in  otology,  aud  of  the  incre.^eu  ^.  .^^  ^^^^  valuable  mHteri-il.  Such  a  book  as 
int.  rest  manifested  in  It,  the  medical  profession  will  j,,/  .g,^^,  ^„e  .l,i„k,  haslongbeen  needed,  and 
welcome  this  new  work  which  presents  clearly  and  ^  P  ,,^  ^.^^i^^e  the  author^on  his  success  in 
concisely  us  present  '^^"^^l^  ^}^l^\^l^^lll'''^^X  filling  the  gip.  Both  scudent  and  practitioner  can 
eating  the  direction  in  which  fur  her. esearehes  can     ^^.^^  «  °^P  deal  of  benefit.     It  is 

be  most  profitably  carried  on      JJr^  Bu.n  "  nom  h.^^    pr.fu-ely  and    beautifully  iilustrated.-i^'.  Y.  Eos- 
own   matared  experience,  and  availing  himself  oi    '^       ,  ^;',^,,.   ^^t   is   ic-., 
the  observations  and  discoveries  of  others,  has  pro-    P'tal  Gazette,  Oct   lo,  IS/ 7. 

duced  a  work,  which  as  a  text-book,  stands /'(ciZe  1  Dr.  Burnett  is  to  be  commended  for  having  written 
■nrincep.s  in  our  language.  "We  bid  marked  several  |  the  best  book  on  the  subject  in  the  English  language, 
pa-sa2es  as  well  worthy  of  quotation  and  the  alien- !  and  especially  for  the  care  and  attention  he  has 
tion  oT  the  general  practitioner,  but  their  number  and  given  to  the  scientific  side  of  the  subject. — N.  Y. 
the  space  at  our  command  forbid.  Perhaps  it  is  bet-  Med  Journ.,  Dec.  1S77. 
ter,  as  the  book  ought  to  be  in  Ihe  hands  of  every  . 

r'AYLOR  [ALFRED    S.),M.D., 
Lecturer  on  Med.  Jurisp.  and  0 tiemisiry  in  Guy's  So.fxntal. 

POISONS  IN  RELATION  TO  MEDICAL  JURISPRUDENCE  AND 

MEDICINE.  Third  American,  from  the  Third  and  P.,evised  English  Edition.  In  one 
large  octavo  volume  of  SoO  pages;  cloth,  §5  50  ;  leather,  |6  50.  {J^ist  Issued.) 
Tbe  present  is  based  upon  the  two  previous  edi-  ,  being  described  which  give  rise  to  legal  iLvestiga- 
tions;  "butthecompleieTevisiou  rendered  necessary  ,  tions.  — :2'Ac  Clinic,  >ov.  6,  1S7.9. 
by  time  has  converted  it  into  a  new  work."  This;  Dr.  Taylor  hat  brought  to  bear  on  the  compilation 
statement  from  the  preface  contains  all  that  it  is  de-  j  „/  ^jjjg  volume,  stores  of  learning,  experience,  and 
sired  to  know  in  reference  to  the  new  edition.  The  ]  practical  acquaiLtance  with  his  subject  probably  fur 
works  of  this  author  are  already  in  th«  library  of  j  beyond  what  any  other  living  authority  on  toxicol- 
every  physician  who  is  liable  to  be  called  upon  for  ;  ogy  could  have  amassed  or  utilized.  He  has  fully 
medi'eo-legal  testimony  (and  wh  t  nei.>  not?;,  sothat  |  sustained  bis  rCfjUtation  by  the  consummate  skill 
all  that  is  required  to  be  knowu  about  the  present  i  ^^j  legal  acumen  he  has  displayed  in  the  arrange- 
book  is  that  the  author  has  kept  it  abreast  wiih  the  mem  of  tne  subject-matter,  and  the  result  is  a  work 
times.  What  makes  it  now,  as  always,  especially  ^  y„  poisous  wliicn  will  be  indispensable  to  every  btu- 
valudble  to  the  practitioner  is  its  conciseness  ani  ,  jent  or  practitioner  in  law  and  medicine. — The  Duo- 
practicalcharacter,  only  those  poisonous  substances    Ua  Journ.  K-f  Med   Sci.,  Oct.  1S7.5. 

75 r  THE  SAME  AUTHOR. 

MEDICAL  JURISPRUDENCE.   Seventh  American  Edition.   Edited 

by  John  J.  Reese,  M.D.,  Prcf  of  Med.  Juri-<p.  in  the  Univ.  of  Penn.  In  one  large 
octavo  volume  of  nearly  900  pages.     01oth,§5  DO;  leather,  $6  00.     {Late/y  Issued.) 

To  tbe  members  of  the  legal  and  medical  profes-  best  aaihority  on  this  specialty  in  our  language.  On 
siou  It  is  unuece:<sary  to  say  anything  commenda-  this  point,  however,  ive  will  -ay  that  weconsider  Di . 
tory'of  Taylor's  Medical  Jurisprudence.  We  might  Taylor  to  be  thesafe-<l  medico-legal  aalliority  Jofol- 
as  well  undertake  to  speak  of  the  nerit  of  Chilly's  low,  ingeneral,  with  which  we  areacqiiaintedin  any 
Pleadings.— C'/2ic'/po  Legal  Ntws,  Oct.  It;,  1S7X.  language.— Ka   Ulin.  liecird.  -Nov.  1»73. 

It  is  beyond  question  the  most  attractive  as  well  This  las  ted  ition  of  the  Manual  is  probably  Ihe  best 
as  most  reliable  manual  of  medical  jurisprudence  of  ah,*.'*  it  contains  more  material  and  is  worked  up 
published  in  the  English  \tt.n$na.ge.—Arn.  JouT7tal  to  the  latest  vi  w»  .>t  the  au i nor  asex pressed  in  tbe 
of  Syphilography,  Oct.  1&73.  Iji^t  edition  of  the  Principles.    Dr.  Keesc,  the  editor 

It  isaltogethersuperfluousforustooffer anything    of  the  Manual,  has  done  everything  to  make  his 
iu  behalf  of  a  work  on  medicaljurisprudence  by  an     ?rorkacceptable  to  bis  medical  countrymen. — S.  \. 
author  who  is  almost  universally  esteemed  to  be  (be    Mad.  Sxcurd,  Jan.  l.').  Is?!. 
i>r  THE  SAME  AUTHOR.  

THE  PRINCIPLES  AND  PRACTICE  OF  MEDICAL  JURISPRU- 

DENCE.     Second  Edition,  Revised,  with  numerous  Illustrations.    In  two  large  octavo 

volumes,  cloth,  $10  00  ;  leather,  $12  00 
This  great  work  is  now  recognized  in  England  as  the  fullest  and  most  authoritative  treatise  on 
every  department  of  its  important  .subject.   In  laying  it,  in  its  improved  form,  before  the  Amer- 
ican profession,  the  poblisher  trusts  that  it  will  assume  the  same  position  in  this  country. 


ITknry  C.  Lka's  Publications — [AlisreUaneoufi). 


31 


HOMPSON  [SIR  HENRY), 

Surgeon  and  Professor  of  Olinicnl  Surgery  to  University  College  Hospital . 

LECTURES  ON  DISEASES  OF  THE  URINARY  ORGANS.  With 

illustrations  on  wood.     Second  Aiuerican  from  the  Third  Engli.^h  Edition.     In  one  neat 
octavo  volume.     Cloth,  $2  25.     {Just  Issued.) 

y   TIIK  SAME  AUTHOR.  


T 


75 

ON  THE  PATHOLOGY  AND  TREATMENT  OF  STRICTURE  OF 

THE  UKETIIHA  AND  URINARY  FISTULA.  With  plates  and  wood-cuts.  From  the 
third  and  revised  English  edition.  In  one  very  handsome  octavo  volume,  cloth,  $3  51). 
{Li/te/y  Puhlisked.). 

OBERTS  [WILLIAM],  M.D., 

LeiHurer  on  Medicine  in  the  Manchester  School  of  Medicine,  etc. 

A  PRACTICAL  TREATISE    ON  URINARY  AND  RENAL  DIS- 

E.A.SES,  including  Urinary  Deposits.  Illustrated  by  numerous  cases  and  engravings.  Sec- 
ond American,  from  the  Second  Revised  and  Enlarged  London  Edition.  In  one  large 
and  handsome  octavo  volume  of  616  pages,  with  a  colored  plate  ;  cloth,  $4  50.  (Laiely 
Puhlisked.) 

rpUKE  [DANIEL  HACK),  M.D  , 

■*■  Joint  author  of  "  The  Manual  of  Psychological  Medicine,"  &o. 

ILLUSTRATIONS  OF  THE  INFLUENCE  OF  THE  MIND  UPON 

THE  BODY  IN  HEALTH  AND  DISEASE.  De.^igned  to  illustri.te  the  Action  of  the 
Imagination.  In  one  handsome  octavo  volume  of  41 6  pages,  cloth,  $3  25.  {Lattly  Issued.) 


R 


B 


LANDFORD  [G.  FIELDING),  M.D.,  F.R.C.P., 

Lecturer  on  Psychological  Medicine  at  the  School  of  St.  George's  Hospital,  Sec. 

INSANITY"  AND  ITS  TREATMENT:   Lectures  on  the  Treatment, 

Medical  and  Legal,  of  Insane  Patients.  With  a  Summary  of  the  Laws  in  force  in  the 
United  States  on  the  Confinement  of  the  Insane.  By  Isaac  Ray,  M.  D.  In  one  very 
handsome  octavo  volume  of  471  pages;  cloth,  $3  25. 

It  satisfieo  a  want  which  must  have  been  sorely  \  actually  seen  in  practice  and  the  appropriate  treai 


felt  by  the  busy  gene  ralpractitionerb  ofthib  country 
Ic  takes  the  form  of  a  manual  ofcliuical  dosciiptiun 
of  the  various  forms  of  insanity,  with  a  description 
of  the  mode  of  examining  persons  Bu.spected  of  in- 
sanity. We  call  particular  attention  to  this  feature 
•>f  the  book,  as  givingit  a  uninue  value  to  the  gene- 
ral practitioner.  If  we  pass  from  theoretical  eonsidc- 
rations  to  descriptionK  of  the  varieties  of  insanity  a^ 


ment  for  them,  we  find  in  Dr.  Blaudfurd's  work  a 
considerable  advance  over  previous  writings  on  tie 
subject.  His  pictures  of  the  various  forms  of  mental 
disease  are  so  clear  and  good  that  no  reader  can  fail 
to  be  struck  with  their  superiority  to  those  given  in 
)idinary  manuals  in  the  English  language  or  (so  far 
as  our  own  reading  exiends;in  any  other. — London 
Practitioner,  Feb.  1871. 


EA  [HENRY  C). 
'  SUPEllSTITION    AND   FORGE:    ESSAYS   ON   THE   WAGER   OF 

LAW,  THE  WAGER  OF  BATTLE,  THE  ORDEAL,  AND  TORTURE.  Third  Revised 
and  Enlarged  Edition.  In  one  handsome  royal  12mo.  volume  of  652  pages.  Cloth, 
$2  50.      {Just  Ready.) 


The  appearance  of  a  new  edition  of  Mr.  Henry  C. 
Lea'.s  "siuperslition  and  Force"  is  a  S!gn  that  our 
highest  scUolar^hip  is  not  without  lionor  in  its  ua- 
tlt-e  country.  Mr.  Lea  has  met  every  fresh  demand 
lor  his  work  with  a  careful  revision  of  it,  and  the 
present  eattion  is  not  only  fuller  and,  if  possible, 
more  accurate  than  either  of  the  preceding,  but, 
from  the  thorough  elaboration  is  more  like  a  har- 
monious concert  and  less  like  a  batch  of  studies. — 
Tne  Anti'in,  Aug.  1,  1S7S. 

Many  will  be  tempted  to  say  that  this,  like  the 
'■  Decline  and  Fa II, "is one  of  the  ancriticizable  books 
Its  facts  are  innumerable,  its  deductions  simple  and 
inevitable,  and  its  chevattx-di-fri-ie  of  references 
bristling  and  dense  euuugh  to  make  the  keenest, 
stoutest,  and  best  equipped  assailant  think  twice 
before  advancing.  Nor  is  there  anything  contro- 
versial in  it  to  provoke  assault.     The  author  is  no 


polemic.  Though  be  obviously  feels  and  thinks 
strongly,  he  succeeds  in  attaining  impartiality. 
Wheti  er  looked  on  as  a  picture  or  a  mirror,  a  work 
such  as  this  has  a  lasting  valae. — LippincotVs 
Magazine,  Oct.  1S7S. 

llr.  Lea's  curious  historical  monograph.",  of  which 
oi;e  '  f  the  most  important  is  here  reproduced  in  an 
enlarged  form,  have  given  him  an  unique  position 
among  Eoglisli  and  American  scholars.  He  is  dis- 
tinguished for  his  recondite  and  aflluent  learning, 
his  power  of  exhaustive  historical  analysis,  the 
breadth  and  accuracy  of  his  researcht-s  among  the 
rarer  sources  of  knowk-dge,  the  gravity  and  temper- 
ance of  his  statements,  combined  with  singular 
earnestne.^s  of  conviction,  and  his  warm  attachment 
to  the  cau-e  of  human  freedom  and  intellectual  pro- 
gres.s.— iV.  Y.  Tribune,  Aug.  9,  1S7S. 


B 


T  THE  SAME  AUTHOR.    {Cafe  y  Published.) 

STUDIES  IN  CHURCH  HISTORY— THE  RISE  OF  THE  TEM- 
PORAL POWER— BENEFIT  OF  CLERGY— EXCOMMUNICATION.  In  one  large 
royal  l2mo.  volume  of  516  pp.;  cloth,  $2  75. 


The  story  was  never  told  more  calmly  or  with 
gr  >ater  learning  or  wiser  thought  We  d  oibt,  indeed, 
if  -iny  other  study  of  this  field  can  be  compared  with 
tais  for  clearness,  accuracy,  and  power.  —  Chicago 
Examiner,  Dec.  1870. 


lasa  peculiar  importance  for  the  English  student. and 
is  a  chapter  on  Ancient  Law  likely  to  be  regarded  as 
lual.  We  can  hardly  pas'-  from  our  mention  of  such 
works  as  these — with  which  that  on  "Sacerdotal 
1  C    lihftcv"  ahonld   bo  iuclnded — witbonl  notinptbo 


Mr  Lea's  latest  work, -'Studies  in  Church  History."  literary  phenomenon  thai  the  heaa  of  one  ol  the  first 
fully  sustains  the  promise  of  the  tjrst.  It  deal-  with  American  hon.sPs  i.^  al.=o  the  writer  of  some  of  its  rrost 
three    subjects— the  Temporal    Power.    Benefit   oflongiaa,!  ho(i)LS.— London  Athtnaum,  Jun.  7,  ISU. 


Clergy,  and  Excommunication,  the  record  of  which 


32 


Henry  C.  Lea's  Publications. 


INDEX   TO    CATALOGUE. 


try 

try 


HartKhorne'R  Anatomy  and  Pliysiology 
Hamilton  on  Nervous  Diteaeea 
Heath's  Practical  Anaiorny 
Hoblyn's  Medical  Dictionary 


nts 


PAiiF. 

American  Journal  of  the  Medical  Sciences        .      1 

Abstraci,  .Monthly,  of  the  Med.  Sciencet 

Allen's  Anaiomy    ..... 

Anatomical  Atlas,  by  Smith  and  Horner 

Ashton  on  the  Kectum  and  Anus 

Attfield's  Chemistry    . 

Ashwellon  Disease.'?  of  Females 

Ashhnrst's  Surgery 

Browne  on  Ophthalmoscope  . 

Browne  on  the  Throat     . 

Burnett  on  the  Ear 

Barnes  on  Difeases  of  Women 

Barnes'  Midwifery, 

Bellamy's  Surgical  Anatomy     .. 

Bryant  s  Practical  Surgery 

Bloxam'B  Chemistry     .     "   . 

Blandlord  on  Insanity  . 

Basham  on  Renal  Disea.^es  . 

Brinton  on  the  Stomach 

Barlow's  Practice  ol  Medicine 

Bowman's  (John  E.)  Practical  Chem 

Bowman's  (John  E.)  Medical  Chemis 

Bristowe's  Practice 

Bumstead  on  Venereal 

B^imstead  and  CuUerier's  Atlas  of  Venereal 

Ca,rpenter's  Human  Phy.sioiogy 

C  trpenter  on  the  Use  and  Abuse  of  Alcohol 

Corniland  Ranvier 

Carter  on  the  Eye  . 

Cleland's  Dissector 

Classen's  Chemistry 

Clowes'  Chemistry 

Century  of  American  Medicine    . 

Chadwick  on  Diseases  of  Wc.men 

Charcot  on  the  Xerrons  Sy.-tem    . 

Chambers  on  Diet  and  Regimen  . 

Chambers's  Restorative  Medicine 

Christison  and  Griffith's  Dispensatory 

Churchill's  System  of  Midwifery 

Churchill  oa  Puerperal  Fever 

Condie  on  Diseases  of  Children  . 

Cooper's  (B.  B.)  Lectures  on  Surgery 

CiUerier's  Atlas  of  Venereal  Diseases 

Cyclopaedia  of  Practical  Medicine 

Dalton's  Human  Physiology 

Davis's  Clinical  Lecturer 

Dewees  on  Diseases  of  Females  . 

Drnitt's  ModernSurgery 

Danglison's  Medical  Dictionary 

Elli.s'8  Demonstrations  in  .\naiomy 

Erichsen's  System  of  Surgery 

Emmet  on  Diseases  of  Women 

Farquharson's  Therapeutics 

Fenwick's  Diagnosis 

Finlayson's  Clinical  Diagnosis 

Flint  on  Ee.spiratory  Organs 

Flint  on  tlie  Heart 

Flint's  Practice  of  Medicine. 

Flint's  Essays 

Flint's  Clinical  Medicine 

Flint  on  Phthisis    . 

Flint  on  Percus.-iun 

Fothergill's  Handbook  ofTreatment 

Fothergill's  Antagonism  of  Theiapeutic  Age 

Fownes's  Elementary  Chemistry 

Fox  on  Diseases  of  the  Skin 

Fuller  on   the  Langs.  &c. 

Green's  Pathology  and  Morbid  Anatomy 

Gibson's  Surgery 

Glnge's  Pathological  Histology,  by  Leidy 

Gray's  Anatomy 

Galloway's  Analysis       .... 

Griffith's  (R.  E.)  Universal  Formulary 

Gross  on  Urinary  Organs.     . 

Gro.sg  on  Foreign  Bodies  in  Air-Passages 

Gross's  Principles  knd  Practice  of  Surgery 

Habershon  on  the  Abdomen  . 

Hamilton  on  Dislocations  and  Fractures 

Hartshorne's  Essentials  of  Medicine 

Hartsnorne's  Conspectus  of  the  Medical  Sciences    6  ; 


10 
1.9 
1.5 

19 
19 
16 
16 
10 
17 
19 
14 
2,!i 
14 

H 

9 
12 
26 
26 
26  i 
16  I 

29  : 
1.-) 


Hodge  on  Women  ...... 

ioctge's  Obstetrii-s         .         .  .         . 

lolland's  Medical  2Jotes  and  Reflections   . 
Ho' mes's  Surgery  ...  .        . 

Holden's  Landmarks  .... 

-lorner's  Anatomy  and  Histology 
Hudson  on  Fever   ...... 

Hill  on  Venereal  Diseases    . 
Hillier's  Handbook  ol  Skin  Diseases 
Jones  (C.  Handfield)  on  Nervous  Disorders 
Kirkes'  Physiology       ..... 

Knapp's  Chemical  Technology   . 
Lea's  Superstition  and  Force 
Lea's  Studies  in  Church  History 
Lee  on  Syphilis      .... 

Lincoln  on  Electro-Therapeutics 
Leishman's  Midwifery  . 
La  Roche  on  Yellow  Fever. 
La  Roche  on  Pneumonia,  &c. 
Laurence  and  Moon's  Ophthalmic  Surgery 
Lawson  on  the  Eye       ... 
Lehmann  s  Physiological  Chemistry,  2  vols 
Lehmann's  Chemical  Physiology 
Ludlow's  Manual  of  Examinations    . 
Lyons  on  Fever     ..... 

Medical  News  and  Library  . 

Meigs  on  Puerperal  Fever    . 

Miller's  Practice  of  Surgery 

Miller's  Principles  of  Surgery     . 

Montgomery  on  Pregnancy 

Neill  and  Smith's  Compendium  of  Med.  S 

Obstetrical  Journal       .... 

Parry  on  Extra-Uterine  Pregnancy 
Pavy  on  Digestion        .... 

Pavy  on  Food 

Parrish's  Practical  Pharmacy 

Pirrie's  System  of  Surgery  . 

Playfair's  Midwifery     .... 

Quain  and  Sharpey's  Anatomy,  by  Leidy 

Reynolds'  Practice  of  .Medicine  . 

Roberts  on  Urinary  Diseases 

Ramsbotham  on  Parturition 

Remsen's  Principles  of  Chemistry 

Rigby's  Midwifery         .... 

Rudwell's  Dictionary  of  Science  . 

Stimson's  Operative  Surgery 

Swayne's  Obstetric  Aphorisms    . 

Seller  on  the  Throat        .... 

Sargent's  Minor  Surgery 

Sharpey  and  Quain's  Anatomy,  by  Leidy 

Skey's  Operative  Surgery     . 

Slade  on  Diphtheria      .... 

Schafer's  Histology        .... 

Smith  (J.  L.)  on  Children 

Smith  (H.  H.)  and  Horner's  Anatomical  Atlas 

Smith  (Edward)  on  Consumption 

Smith  on  Wasting  Diseases  in  Children 

Still6's  Therapeutics      .... 

Siille  &  Maisch's  Dispensatory    . 

Starges  on  Clinical  Medicine 

Stokes  on  Fever    ..... 

Tanner's  Manual  of  Clinical  Medicine 

Tanner  on  Pregnancy    .... 

Taylor's  Medical  Jurisprudence 

Taylor's  Principles  and  Practice  of  Med    J 

Taylor  on  Poisons 

Tuke  on  the  Influence  of  the  Mind 

Thomas  on  Diseases  of  Females  . 

Thompson  on  Urinary  Organs 

Thompson  on  Stricture  . 

Todd  on  Acute  Diseases 

Woodbury's  Pr>ictice 

Walshe  on  the  Heart 

Watson's  Practice  of  Physic 

Wells  on  the  Eye  .... 

West  on  Diseases  of  Females 

West  on  Diseases  of  Children 

West  on  Nervous  Disorders  of  Children 

What  to  Observe  in  Medical  Cases 

Williams  on  Consumption    . 

Wilson's  Haman  Anatomy  . 

Wilson's  Handbook  of  Cntaneons  Medicin 

Wiihler'g  Organic  Chemistry 

Winckel  on  Childbed    . 


PAOR 
21 


arls 


HENRY  C.  LEA— Philadelphia. 


A 


^ 


r 


H8 


4  ims 


